









LIBRARY OF CONGRESS. 

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UNITED STATES OF AMERICA. 



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THE 



PRACTITIONERS 



Guide in Urinalysis. 



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BY 



CLIFFOKD MITCHELL, A. B., M. D. 



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Author of " Manual of Urinary Analysis," ''Clinical Significance 

of the Urine. " etc. 



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ILLUSTRATED 



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DEC 13 



CHICAGO: 
GROSS & DELBEIDGEi 

18 82. 



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COPYRIGHT BY 

GROSS & DELBRIDGE, 

1882. 






PREFACE 



The object of the present little work is to enable the 
practitioner of but little experience in the use of chemi- 
cals and the microscope, to ascertain as accurately and 
rapidly as possible the physical characteristics of the urine, 
to determine its constituents, normal and abnormal, the 
contents of sediments, etc., etc., and after the various sub- 
stances entering into the composition of the fluid have been 
ascertained by analysis, to teach the clinical significance 
of the same. With this end in view, the book is divided 
into two parts : I. Practical, and II. Clinical. In Part 
I. the methods of analyzing urine have been set forth 
together with the microscopical appearances of deposits, 
etc., in the simplest and plainest language possible. At 
the end of every few pages a « Clinical Summary" is 
given explaining in condensed and general terms the 
clinical significance of everything ascertained up to that 
point by chemical or microscopical means. The clinical 
hints and aids to diagnosis given in Part I. are more 
widely touched upon in Part II., and some little attention 
given to the more recent discoveries in urinary pathology. 
The order in which the book is written enables the 
hurried practitioner to find everything of the greatest 
consequence in routine practice in Part I. ; in doubtful 
cases where more study and attention must be given it is 
hoped that Part II. may be of aid. Inasmuch as few 
works on the urine go into detail in describing chemical 
apparatus, reagents, etc., an introduction to Part I. has 



PREFACE. 



been arranged in which even the simplest matters relating 
to the use of chemicals and the microscope have been ex- 
plained. In describing chemical tests the physician may 
here and there find a well-known one omitted, but this has 
been done only where, in the author's experience as a 
teacher, he has seen it cause confusion. Moreover in 
describing tests for important abnormal constituents 
a simple clinical test has been given first, followed by a 
more thorough and conclusive one. 

Chemical terms, when used, are simplified as far as 
possible without being actually inaccurate. Among the 
large number of writers from whose works and articles the 
author has collected his facts, he is especially indebted to 
Vogel and Balfe, for aid in studying the clinical signifi- 
cance of urine; to Senator, who in his recent work 
entitled " Die Albuminuric," has discussed at considerable 
length the so-called "normal albumin," and to Prof. E. 
H. Wood, of the Harvard Medical School, for his plea in 
favor of the "twenty-four hours urine" in cases of 

Bright' s disease. 

Observations of the author on the daily quantity and 
specific gravity of normal urine as observed by him during 
a period of some fifty days, together with such cases in 
his own analytical practice as have been of especial in- 
terest to him, will be found in part Part II. (See also 
Appendix.) 

Chicago, III., 

296 Erie Street, 

September /, 1882. 



I^TEODUOTIOX. 



TEST-TUBES.— Most of the work to be clone in examin- 
ing a specimen of urine requires some familiarity with the 
use of test-tubes, Fig. 1 — small glass cylinders closed at one 





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Fig. i. 



end and open at the other. Test-tubes holding one-half 
a fluid ounce are of convenient size in urine analysis ; when 
filled with any liquid they should be stood in the apertures 
of a test-tube rack or stand (Fig. 1); when cleaned, a 
test-tube brush should be used, which is merely two wires 
twisted together, holding at one end a number of bristles. 
Test-tubes are so called from the fact that in them 
"tests" are conveniently made; a specimen of urine is 
said to be "tested" for any substance it may contain 
when certain processes, chemical or physical, are gone 
through with, with a view to ascertain whether or not the 



INTRODUCTORY. 



m 



= 



substance be present in the urine. Thus, a "test" is said 
to be made for albumin when the urine, supposed to con- 
tain it, is heated, or when nitric acid is added, etc. 

After a test has been made the test-tube which has 
been used should at once be cleaned ; if it 
be not convenient for any reason to do this 
the tube may stand in the rack until all 
work of the kind has been finished, when 
all the test-tubes which have been used may 
be cleaned at one time. , It is not advisable 
to allow urine to remain in the tubes for 
any length of time especially when to it 
have been added various reagents. 

Never stand a test-tube in a cup, glass or 
leaker, hit always in the rack. 

To clean the tubes pour out the liquid 
contained in them, if any, rinse out with 
water, which if possible should be warm, 
then filling half or two -thirds full of water 
introduce the test-tube brush and work it 
to and fro carefully pushing it down to the 
very end of the tube. After the tubes have 
been washed they should be inverted over 
the pegs in the rack to dry. 

Never use a dirty test-tube, and never per- 
form more than one test at a time in one 
tube, unless particularly directed. 
If the tubes cannot be thoroughly cleaned with water, 
try acids, ammonia, alcohol, or ether. 

How to heat or boil urine. — To heat urine fill the test- 
tube half-full and hold over an alcohol-lamp flame gently 
moving the tube from side to side so as to prevent boil- 
ing ; when it is necessary to boil the urine, take a strip 



Fig. 2. 



IKTRODUCTOKY. 7 

'of paper four or five inches long, and say, half an inch 
wide, fold it around the tube a little above the point coi 
responding to the surface of the liquid inside, press the 
two ends of the paper tightly together keeping the tips of 
the thumb and forefinger against that part of the paper 
which envelopes the tube, then hold the tube cautiously 
over the flame until it boils. 

It is not desirable to use a gas flame for heating or 
boiling urine inasmuch as the test-tube becomes covered 
with soot and if the flame be too strong there is danger 
of cracking the tube unless it be kept actively in motion. 

With an alcohol-lamp flame urine can be boiled for 
some time without bubbling over, if due care be exercised. 

In testing urine always notice whether the directions 
given in the "Manual" used are to heat or to boil, and if 
the former is specified, remove the test-tube from the 
flame before the first sign of ebullition. 

If any reagent to be boiled, as Fehling's solution, have 
a tendency to "bump," i. e., suddenly and without warn- 
ing to boil over, add a few fragments of an ordinary clay- 
pipe which must be clean and new. 

TEST-GLASSES. — Next in importance to test-tubes are 
the glasses in which urinary sediments are collected. 

To collect a sediment or deposit, allow the urine to 
stand at rest in a tall, narrow, cylindrical glass vessel 
like the one shown in Fig. 2 ; the best are those pro- 
vided with a lip. After the deposit has settled to the 
bottom of the test-glass, remove the clear urine by de- 
cantation. 

To decant urine hold the test-glass very steadily in the 
right hand ; against the lip hold with the left hand a 
glass rod, grasping the latter near its upper end. 

Next incline the test-glass in such a way as to pour 



8 INTRODUCTORY. 

the urine down the rod into any vessel desired. Cease 
pouring the moment any of the sediment is seen to slip 
out. 

It is well to have one test-glass which is graduated 
either in centimetres or fluid ounces, large enough to 
hold four or five of the latter and provided with a foot 
or base. 

PIPETTES. — To examine a sediment with the micro- 
scope there is need of the little instrument called a pipette, 
which is merely a slender glass tube six to twelve inches 
long with an internal diameter of from -^ to -^ inch and 
drawn out to a pointed end ; the use of a pipette is to 
transfer a drop of urine containing sediment to the glass 
slide used in microscopical work. After the deposit has 
settled to the bottom of the test-glass place the tip of the 
forefinger over the upper end of the pipette and dip the 
lower or pointed end into the sediment. Next remove 
the finger for an instant, then quickly close the orifice 
again with it. A portion of the sediment has passed into 
the pipette and can be held there as long as the finger is 
tightly pressed against the orifice in the upper end of the 
pipette, hence can be carried to a glass slide, when on re- 
moving the finger, the sediment will flow out. 

The best pipette for collecting urinary sediments is (b) 
a glass tube having a calibre of one inch in diameter and 
a length of ten or twelve inches ; one extremity is tapered 
off to a very small orifice and furnished with a glass stop- 
cock. The sediment having been obtained in a test-glass 
as before, decant the supernatant urine, then pour the 
sediment into pipette (b) and allow it to settle. Care- 
fully open the stop-cock and a drop of the densest part of 
the deposit may be received on a glass slide and examined 
with the microscope. 



INTRODUCTORY. 



9 



If is much better to use pipette (b) than the kind 
mentioned first. 

FILTRATION. — Before performing certain tests, as for 
albumin, sugar, etc., it is advisable that the urine be 
filtered ; the apparatus essential to filtration is composed 
of a funnel, filters or filter paper ', 
a filter ring and stand and a 
test-glass. Funnels are of glass 
and of various sizes ; those three 
or four inches in diameter across 
the top are of convenient size. 
Filter paper is unsized and 
many varieties of it are in aim- 

mi 

f actured ; the so-called " Prat- 
Dumas" French filter paper 
comes cut in circular form in 
packs of 100 filters each and is 
the best for the physician's use. 
Filters having a diameter of 7-i- 
inches are of convenient size for 
the funnel mentioned above. 
A filter ring and stand is shown 
in Fig. 3. 

In order to filter, take one 
paper from the package of cut 
filters (or cut out from Swedish 
filter paper a circular piece of 7 or 8 inches in diameter), 
fold in two, next turn over each edge as you would two 
opposite leaves in a book, namely one end from right to 
left and the other from left to right until they just do 
not meet. A funnel shape is in this manner given to the 
paper (Fig. 4). Thus folded, place the filter into the 
funnel, open on the side opposite to where it was last 




Fig. 



10 



INTRODUCTORY 




Fig. 4. 



folded, and fit it closely down into the funnel. Do not 

let the paper project 
over the rim of the 
funnel and before pour- 
ing the urine into it 
moisten with distilled 
water evenly and gently 
from the lowest part 
upward. Having fitted 
the paper to the fun- 
nel and moistened as 
described, next set the 
funnel into the filtering-ring and place a test-glass or any 
glass vessel desired beneath the spout of the funnel. Now 
pour the urine into the funnel after the method of de- 
cantation by means of the glass rod, and when about 
seven-eighths full cease pouring. Observe whether the 
urine trickling through into the test-glass or beaker be- 
neath the funnel be clear ; if not, pour the urine in the 
funnel, into the test-glass, take out the filter paper, throw 
it away and fit a new one. Next take a clean test-glass 
or beaker, place it beneath the spout of the funnel, and 
pour the urine now contained in the first test-glass or 
beaker into the funnel. 

Chemical Examination of Sediment. — If it be desired to 
examine the sediment chemically, w T ait until the urine 
has completely filtered, remove the filter-paper, place it 
in a porcelain dish, make a small hole in it and wash the 
sediment through this hole by means of the ivash-bottle ; 
the latter is a flask or bottle closed w T ith a twice perforated 
snugly-fitting stopper through which two glass tubes are 
passed, each bent above the cork, the one at an acute 
angle the other at an obtuse. When the bottle is filled 



INTRODUCTORY. 11 

with water, blowing through the obtuse-angled tube will 
force a stream of water with considerable violence through 
the acute-angled tube, and any precipitate or deposit 
adhering to the filter paper may be washed off. Ordinarily 
the physician need not have recourse to this method of 
obtaining a sediment as decantation of the supernatant 
urine will answer most purposes, leaving, as it does, the 
sediment at the bottom of the test-glass. 

GLASS JARS. — The physician should own a few half- 
gallon or gallon glass jars in which to collect the urine of 
a patient when the whole quantity for twenty-four hours 
is required ; besides these it is convenient to have a 
cylindrical jar graduated in cubic centimeters or fluid 
ounces, capable of containing 1000 cubic centimetres (a 
little over a quart — two pints two fluid ounces nearly). 
The patient having collected the urine of twenty-four 
hours in one of the half-gallon jars the physician can 
measure the amount by one of the graduated jars. 

Miscellaneous. — Besides the instruments mentioned thus 
far it is desirable to have three pipettes graduated in 5, 
10, and 20 cubic centimetres, an alcohol lamp, three or 
four porcelain dishes of different sizes, a small chemical 
thermometer for taking the temperature of urine, three 
or four glass rods, a pair of small brass forceps, litmus 
paper, both red and blue, readily obtained in little books, 
and an urinometer and beaker (see Specific Gravity). 

CHEMICAL REAGENTS.— Chemicals used in testing 
the urine are called reagents, the chemical processes being 
known as reactions. 

The following are useful in urinalvsis : 

Nitric acid, chemically pure, kept away from light and 
in glass-stoppered bottle. 



12 INTRODUCTORY. 

Hydrochloric acid, chemically pure, kept away from 
ammonia in glass-stoppered bottle. 

Acetic acid of two kinds, (i.) pure glacial and (ii.) 
dilute — one part glacial to five parts distilled water, in 
glass-stoppered bottles. 

Sulphuric acid, chemically pure, colorless, in glass- 
stoppered bottle. 

Nitric acid, commercial, containing Nitrous acid, in 
glass-stoppered bottle. 

Trichloracetic acid, pure in crystals, in tightly-stoppered 

bottle. 

Ammonia, one part strongest to three parts distilled 

water. 

Potassa, one part solid caustic potash to ten parts 
distilled water by weight. 

Silver nitrate, one part crystals to ten parts distilled 
water by weight, kept from the light. 

Barium chloride, solution of the same proportions as 
the silver nitrate. 

Potassium ferrocyanide, solution of the same propor- 
tions as the silver nitrate. 

Fehling's solution — described under Sugar. 

Chlorinated Soda, IT. S. P. — preferably Squibb's. 

Alcohol, 95 per cent. 

Spirits Turpentine. 

Tincture Guaiac. 

Ammonium moiybdate in solution. 

Caustic Potash, in sticks, kept in a £or#-stoppered bottle. 

Distilled water in a glass-stoppered bottle holding one 
quart or more. 

Condensed yeast, to be bought fresh whenever needed. 

CHEMICAL TERMS. — Add nitric acid, add ammonia, 
etc. When the term "add" is used without specifying 



INTRODUCTORY. 13 

the amount, neither too much nor too little of the reagent 
should be added to the urine ; if the test-tube be half full 
of urine fifteen to thirty drops of the reagent may be used. 

Alkali, Alkaline, Alkalinity. — An alkali is a compound 
substance very soluble in water, turning red litmus paper 
blue, and opposed in its properties to the characters of 
sour or acid substances. The alkali most familiar to every 
one is ammonia which from its well-known tendency to 
evaporate is called a volatile alkali. Potash and soda are 
called on the other hand fixed alkalies. The urine is said 
to be alkaline when a piece of red litmus paper dipped into 
it is turned blue ; in such a case an alkali of some sort is 
present in the urine and we speak of the alkalinity of the 
latter. 

Acid, Acids, Acidity. — The sour substances called acids 
are of several varieties ; mineral acids are very corrosive, 
generally liquid in form and have a powerful action on 
the skin, clothing, etc. Those used in urinary analysis 
are nitric, hydrochloric and sulphuric. They are corrosive 
poisons. Stains caused by acids are best removed by 
ammonia; nitric acid stains, however, must be washed 
repeatedly with a concentrated solution of potassium per- 
manganate, then with water. Eemove the brown stain of 
the permanganate by an aqueous solution of sulphurous 
acid. 

Vegetable acids are less corrosive than mineral acids but 
are frequently poisonous ; the most important acid of this 
class used in urinary work is acetic acid. An acid 
substance may be recognized by its power of neutralizing 
an alkali (either entirely or partly), that is, destroying the 
characteristic properties of the latter. 

Acids turn blue litmus paper red and when the urine 



14 INTRODUCTORY. 

has this effect upon such paper it is said to be acid and 
we speak of its acidity. 

In case a strong mineral acid be accidentally taken 
internally an alkali must be administered as an antidote 
such as dilute carbonate of soda, magnesia with milk or 
water, carbonate of lime, mixture of soda; if an alkali be 
swallowed by mistake the antidote is an acid solution such 
as vinegar and water equal parts, lemon juice, or the like. 
The same substances may be used for external injuries 
from strong acids or alkalies as the case may be, alkalies 
for acid burns and acids for alkali burns. 

Salts. — A salt is a compound substance containing an 
acid in combination with a base (the latter term being 
applied to any compound body capable of neutralizing an 
acid partly or entirely as oxide of zinc, any of the alkalies, 
etc., etc.) ; a salt may also consist of a metal in combina- 
tion with chlorine, bromine, iodine, etc. It is not necessary 
that the practitioner trouble himself greatly about these 
definitions; in this book when we speak of calcium 
carbonate we mean a salt of calcium containing carbonic 
acid in combination, when of potassium nitrite a salt of 
potassium containing nitrous acid in combination, when of 
sodium chloride a salt of sodium containing chlonw*. 

A solution of ammonia, soda, or potassa is often called 
solution of ammonium hydrate, sodium hydrate, etc. ; in 
familiar language these may also be termed solution of 
caustic potash, solution of caustic soda, etc. 

Precipitate. — When a reagent is added to urine and a 
cloudiness or turbidity ensues some substance which here- 
tofore has been dissolved in the urine appears and causes 
this cloudiness, the urine on addition of the reagent no 
longer being able to hold the substance dissolved, or else 
some new and insoluble substance being formed from a 



INTRODUCTOKY. 15 

combination of the reagent with some constituent of the 
urine, a turbidity is seen. Thus if nitric acid be added 
to urine containing albumin the latter is seen in the form 
of a cloudiness or turbidity since the acid has rendered the 

as 

urine incapable of holding the albumin dissolved ; similarly 
if silver nitrate be added to urine a dense turbidity is at 
once seen caused by the formation of silver phosphate and 
silver chloride, both of which salts are insoluble in urine. 
The technical term for the cloudiness or turbidity thus 
produced is " precipitate " ; albumin may be said to be 
precipitated on adding nitric acid to urine, and silver 
chloride may be said to be precipitated on adding silver 
nitrate to the urine. 

MICROSCOPE. — The microscopic examination of urine 
is by no means formidable. Urinary sediments containing 
crystals are easily recognized and it is only in the case of 
tube casts, blood, pus, etc., that any great care or ex- 
perience is necessary. Any achromatic microscope provided 
with " objectives " and "eye-glasses" giving a power of 
from 200 to 600 diameters will suffice; the so-called 
"students' microscopes," if from the hands of a good 
maker, are all that are required for urinary work. 

The object to be examined is placed on a glass "slide" 
or in a "cell" covered by a thin glass cover to keep out 
dust, etc., and placed on the "stage"; by means of the 
" objective " (a lens placed on the lower part of the instru- 
ment near the object) and the " eye-glass" (a lens in the 
upper part near the eye), the magnifying pow T er used 
may be determined as follows: if the magnifying power 
of the "objective" is 20 diameters and that of the "eye- 
glass" 10 diameters, 20x10 or 200 diameters is the total 
magnifying power of the microscope. Hence a number 
of different "objectives" and a number of different "eye 



16 



INTRODUCTORY. 



pieces" will give a great variety of powers, but for urinary 
work two objectives are sufficient, namely, a " two-third 
inch" and a "one-fifth inch"; the "two-third inch" 
with different eye pieces will give a magnifying power of 




Fig. 5. 



from 75 to 150 diameters, and the "one-fifth inch" 250 
to 700 diameters ; in case it be not convenient to obtain 
these, the one-half inch and one-fourth inch may be used. 
Physicians, not familiar with the technical terms used by 



IXTK0DUCT0KY. 17 

opticians, in ordering a microscope for urinary work need 
only specify the kind of objectives mentioned above with 
eye-pieces necessary to produce a magnifying power of from 
75 to 150 and 250 to 700 diameters. The microscope is 
so constructed that one "objective" can be taken out and 
another put in with but little loss of time. 

The glass " slides" already mentioned are merely rect- 
angular, flat pieces of glass upon which to place the 
objects to be examined ; they should be kept scrupulously 
clean. The " covers " are of thin glass and are placed 
over the object when the latter is on the slide ; they should 
not press against the object lest it be flattened or crushed. 
In most cases in examining sediments shallow glass or 
gum-dammar <- cells " are better than " slides" since being 
hollowed in form they admit of a stratum of fluid of any 
degree of thickness and the cover when placed is not so 
likely to press the objects. 

Things Necessary for the Microscopical Examination of 
Urinary Deposits. — Microscope, two-third inch objective, 
one-fifth inch objective, several drop pipettes, any number 
of glass slides, thin shallow cells of o-lass or orum-dammar 
and thin glass covers, a flask of distilled water, a piece of 
old linen, a paste-board cover for the microscope, and a 
soft camel's hair pencil. The whole on a table having a 
couple of drawers and placed before a window. Arrange 
the microscope before a window whose aspect is opposite to 
the side on which the sun is shining. Obtain a good light 
at the left hand, then in examination of an urinary deposit- 
proceed as follows : if you have the apparatus described 
under pipette (b.), and have done as described, press the 
pinch-cock and let a drop of the sediment fall on one of 
the shallow cells, cover it over with one of the thin glass 
2T 



18 INTRODUCTOR. T 

covers and remove any urine which may exude at the 
margin of the cover with blotting paper ; next place the 
cell under the microscope, manipulate the mirror so as to 
obtain proper light and examine with a low power, 75 to 
150 diameters, first, as this enables you to see more of the 
deposit, focussing by turning the movement or adjustment 
gently until the eye is suited. In case the ordinary drop 
pipette is used close one end firmly with the forefinger and 
dip the tapering end down to the very bottom of the test- 
glass in which you have allowed the urine to settle, raise 
the forefinger a little so that about an inch of the pipette 
is filled with the sediment, close the finger over the 
aperture tightly, take out the pipette from the test-glass, 
cautiously loosen the finger a little so that about one half 
the sediment drops out, close it again, wipe off the pipette 
with a piece of new linen or muslin held in the left hand, 
then gently raise the fo finger so that a drop of the 
sediment falls on the shallow glass cell, when examine as 
before. This latter method of preparing a drop for ex- 
amination is very troublesome and the physician will do 
well to obtain the instrument described under pipette (b.), 
as it can be ordered of any dealer in chemical apparatus 
in the large cities ; three or four pieces of india-rubber 
tubing fitted with glass jets are supplied with each instru- 
ment and these when not in use are to be kept in a bottle 
of dilute hydrochloric acid to prevent their becoming 
encrusted, being carefully rubbed dry before using. 

The microscope can be kept in good order, etc., (i.) if a 
pasteboard cover be placed over it each time after it has 
been used, (ii.), if strong acids like nitric and hydrochloric 
are not added to the objects on the slides or cells (acetic 
acid will answer in most cases), if (in.) fumes of chlorine, 
ammonia and sulphuretted hydrogen do not take up their 



INTRODUCTORY. 19 

abode near it, if (iv.) any dust on the lenses be removed 
by the camel's-hair pencil, if (v.) spots or finger-stains be 
gently rubbed off the lenses with a piece of moistened, soft 
old linen or kid glove, if (vi.) the surfaces be dried with 
dry, soft old linen, if (vii.) during cold or excessivelv damp 
weather the room be heated so that moisture may not 
form on the lenses, and if (viii.) nobody but the owner 
dust or wipe it. It is perhaps needless to remark that 
"objectives" should not be given to teething children 
wherewith to soothe their aching gums ; various rubber 
appliances of much less cost will answer that purpose with 
less damage to both child and microscope. 

If dust or moisture should have settled on the mirror 
it can be readily wiped off. If any spots should show 
themselves on the field of view when it is illuminated 
by the mirror these are probably due to particles adherent 
to one of the lenses of the eye-piece : and this may be 
determined by turning the eye-piece round which will 
cause the spots also to rotate, if their source lies in it. It 
may very probably be sufficient to wipe the upper surface 
of the eye-glass (by removing its cap), and the lower sur- 
face of the field-glass ; but if, after this has been done, the 
spots should still present themselves, it will be necessary 
to unscrew the lenses from their sockets and to wipe their 
inner surface ; taking care to screw them firmly into their 
place again, and not to confuse the lenses of different eye- 
pieces. Sometimes the eye-glass is obscured by dust of 
extreme fineness which may be carried off by a smart puff 
of breath ; the vapor which then remains upon the surface 
being readily dissipated by rapidly moving the glass back- 
ward and forward a few times through the air. " And it is 
always desirable to try this plan hi the first instance ; 
since, however soft the substance with which the glasses 



20 INTRODUCTORY. 

are wiped, their polish is impaired in the end by the too 
frequent repetition of the process. The best material for 
wiping glass is a piece of soft wash-leather from winch 
the dust it generally contains has been well beaten out 
If the object-glasses (objectives) be carefully handled and 
kept in their boxes when not in use they wall not be likely 
to require cleansing. One of the chief dangers, however 
to which they are liable in the hands of an inexperienced 
microscopist arises from the neglect of precaution m using 
them with fluids ; which when allowed to come in contact 
with the surface of the outer glass should be wiped off as 
soon as possible. In screwing and unscrewing them great 
care should be taken to keep the glasses at a distance 
from the surface of the hands ; since they are liable not 
only to be soiled by actual contact, but to be dimmed by 
the vaporous exhalations from skin which they do not 
touch This dimness will be best dissipated by moving 
the glass quickly through the air. It will sometimes be 
found on holding an object-glass to the light that particles 
either of ordinary dust, or more often of the black coat- 
ins of the interior of the microscope have settled upon 
the surface of the back lens ; these are best removed by 
a clean and dry camels-hair pencil. If any cloudiness 
or dust should still present itself in an object-glass, after 
its front and back surfaces have been careful y cleansed 
it may be unscrewed, cleansed, and screwed together 

again. — Carpenter. u 

S If the microscope be used at night a flat-wicked lamp 
fed with one of the best varieties of paraffine oil will prove 
the most useful light ; place the lamp at the left hand so 
that no light, save that through the microscope, may enter 
the eye. 



INTRODUCTOKY. 21 

MICRO-CHEMICAL REAGENTS. — The chemicals 
necessary for the identification of sediments described in 
this book are, acetic acid, ether, carmine solution, iodine 
water (one grain of iodine, three grains of iodide of po- 
tassium, one ounce of distilled water). 

Acetic acid should be (i.) concentrated and (ii.) diluted 
with from three to five parts water ; for some work the 
strong undiluted acid may be needed, but ordinarily the 
dilute is all that is necessary. 

Carmine solutions may be made in various ways : An 
ammoniacal solution is obtained by dissolving a few grains 
of pure carmine in a little ammonia and diluting with 
distilled water. Filter into a flask, and neutralize the 
solution with a few drops of acetic acid until it has only 
a very slight ammoniacal odor. 

Drop-bottles to hold microscopical reagents are sold, 
and are very convenient as they obviate the use of pipettes. 
The stopper is perforated and is elongated below into a 
fine tube which expands above into a bulbous funnel the 
mouth of which is coverd with a piece of thin india rubber 
tied firmly round its lip. If pressure be made on this 
cover with the point of the finger and the end of the tube 
be immersed in the liquid in the bottle this will rise into 
it on the removal of the finger ; pressure of the finger on 
the cover will now expel the liquid. 

How to Use Reagents. — When in the course of an 
investigation it is required to "add acetic acid," it may 
be quickly accomplished by putting a small drop of the 
sediment on the cell or slide [by either (a) or (b) under 
Pipettes], then dip a clean pipette into the bottle of acetic 
acid and carry a large drop of this reagent to the slide or 
cell where the drop of sediment is and add it to the latter, 
place a thin glass cover over it and examine with the 



22 INTRODUCTOEY. 

microscope. Note carefully what is seen, remove the slide 
or cell from the stage, take a clean slide or cell, place on 
it a fresh drop of the sediment (to which nothing must be 
added), and examine with the microscope, observing what 
changes have been brought about by the addition of 
acetic acid by comparing the sediment to which nothing 
has been added with that to which acetic acid has been 
added. 

If it is desired to note gradual changes on addition of 
a reagent place a drop of sediment on a clean glass slide 
and near it a drop of the reagent, put a thin glass cover 
over the drop of sediment and insert between the slide 
and cover a thread or pointed extremity of blotting or 
filter paper, and by capillary attraction a current will be 
established from the reagent to the sediment. 



METRIC SYSTEM EQUIVALENTS. 



One gramme equals 15,434 -4- Troy grains. 

One thousand cubic centimetres, or 1 litre, equals about 
one quart, wine measure. The litre is the standard of 
liquid measure in the French system and is equivalent to 
1000 cubic centimeters by volume (just as the United 
States wine gallon is equivalent to 231 cubic inches); 
whenever, then, a litre is mentioned the practitioner has 
only to think of a United States quart. Strictly speak 
ing, the litre equals 1.06552 quarts of a United States 
liquid gallon, or in other words, a good full quart. In 
case the quantity of fluid is given in cubic centimetres 
divide by 1000 to obtain the amount in litres, since 1000 
cubic centimetres make 1 litre; thus, given 3500 cubic 
centimetres of urine, to find how many litres or United 
States quarts, divide by 1000 and we have 3i litres ex- 
actly, or 31 United States quarts nearly. 



PART L 



PRACTICAL URINALYSIS. 



PHYSICAL CHARACTERISTICS. 

In making an examination of urine, operations may be 
carried on in the following order : observe 

1. Total quantity in twenty-four hours. 

2. Color and appearance. 

3. Odor. 

4. Keaction. 

5. Specific gravity. 

6. Abnormal constituents — presence and quantity. 

7. Quantity and appearance of deposit — chemical and 
microscopical characteristics. 

8. Presence and quantity of normal constituents. 

The physician should at first perform the operations 
from 1 to 5 inclusive, as directed in pages 25 and 26, 
carefully noting what he finds in each case; then con- 
sult the clinical summary given on page 31. 

Quantity in twenty-four hours. — This may be collected 
by the patient in a clean glass jar, as described in the in- 
troduction. If the jar be graduated in fluid ounces or 
cubic centimetres, the amount passed can be read off very 
quickly and without the extra trouble of measuring in a 
separate vessel. The physician should always have some 
sort of a graduated glass jar for the purpose of measuring 



PRACTICAL URINALYSIS. 25 

the twenty-four hours urine collected by patients, since 
the latter are seldom provided with graduated apparatus 
of any kind ; in case the patient be unable to procure a 
glass jar, any clean vessel capable of holding two quarts 
will answer the purpose unless the patient be diabetic 
when a much larger one may be required. It is unques- 
tionably a great aid to the physician to have the entire 
amount for twenty-four hours under examination, but 
when this cannot be obtained, examine the urine first 
passed on rising, or that passed three or four hours after 
the principal meal. 

Color and Appearance. — Notice whether the urine when 
filtered be (1) pale, (2) normal or (3) highly colored. If 
the urine contain no sediment its color may be readily ob- 
served without filtering by pouring some into a cylindrical 
glass jar of not less than four or five inches in diameter, 
and observing it by transmitted light. 

If the urine contain a sediment the latter must be 
removed by filtration before the color can be accurately 
determined, since a deposit will often be of such a color 
as, when in suspension in the urine, to affect the color of 
the latter ; however, if a sediment be a heavy one (as 
when composed of urates) it may settle completely and 
the color of the supernatant urine can be observed with- 
out the trouble of filtering. 

Pale urine varies from colorless to straw-vellow ; nor- 
mal, from golden-yellow to amber: highly-colored from 
reddish-yellow to brown. Any unusual color of the urine, 
as green, black, blue, etc., should be carefully noticed 
and an explanation sought for in the section, in Part I., 
headed "Color." 

In observing the color of urine, whether it contains a 
sediment or not must necessarily be noticed also ; ascer- 



26 PRACTICAL URINALYSIS. 

tain if possible whether the urine is (1) turbid when first 
passed, or (2) clear when first passed but turbid on cooling. 
Odor. — The odor of urine may be either (1) its own — 
urinous, (2) sweetish, faint whey-like, or that of sour 
milk, (3) ammoniacal, (4) like rotten eggs— sulphu- 
retted hydrogen, (5) that of odoriferous substances intro- 
duced into the organism, as asparagus, etc. 

Reaction. — Ascertain whether the urine be (1) acid, 
(2) alkaline or (3) neutral, as follows: dip or drop two 
pieces of litmus paper, the one blue and the other red, 
into the urine, wait until they are entirely saturated and 
observe whether (1) both are red — reaction acid] (2) 
both are blue — reaction alkaline; (3) one is red and the 
other blue — reaction neutral. 

If the reaction is found to be alkaline, take a slip of 
red paper, saturate it with the urine until it has turned 
entirely blue, then remove it and allow it to dry ; observe 
whether after it is dry it be (1) yet blue or (2) red again. 
Specific Gravity. — To estimate the specific gravity of 
urine it is well to use a specimen of the mixed urine of 
twenty -four hours, owing to variations in the specific 
gravity of urine voided at different times in the day. 
In ascertaining the specific gravity, the little instrument 
called the urinometer is used ; this consists of a glass float 
weighted below with a bulb of mercury and having a stem 
graduated from to 60 at intervals of two degrees, 
usually. The instrument should sink to the zero point 
when floated in distilled water. At 14 on the scale the 
letter H is usually printed to the right, and at 26 the 
letter S; the significance of these letters has been inter- 
preted by some ingenious mind to be "healthy state," 
i. e., if the urinometer sinks to some division on the 
scale between 14 and 26 the urine is " healthy." It is 



PKACTICAL UKINALYSIS. 



27 



customary to call the zero point 1000 and other points 
1014, 1020, etc., prefixing 10 to the numbers on the scale. 
Before using an urinometer for the first time float it in 
distilled water of 60° F. temperature and if it does not 
sink to the zero point or 1000, reject it. In addition to- 
the urinometer procure a glass cylinder or beaker to con- 
tain the urine whose specific gravity is to be taken ; it is 
well to have a beaker of sufficient diameter to allow the 
urinometer to float gracefully without impinging against 
its sides. 

Moreover the beaker or cylinder should have a firm 
base so as not to be easily upset. 

To get the specific gravity of a specimen of urine, 
fill the cylindrical vessel (Fig. 6,) about 
two-thirds full, holding the cylinder 
obliquely while pouring the urine into it 
thus avoiding as much as possible the 
formation of foam — if foam forms re- 
move it with blotting paper. Next let 
the urinometer sink, bulb down, gently 
into the urine being careful not to have 
it touch the sides of the cylinder. When 
it no longer sinks of its own accord, 
stoop down until the eye is on a level 
with the urine and read the number on 
the scale which is even with the lower 
convex edye of the fluid, i. e., not the 
little elevation of liquid which by capillary attraction 
climbs up the stem of the urinometer a short distance, 
but the general surface of the urine. Depress the 
urinometer one degree, allow it to rise, and read again ; 
if the second reading agrees with the first the figure is 
correct. 




Fig. 6. 



28 



PRACTICAL URINALYSIS. 



Patients living at a distance have a provoking habit of 
sending a fluid drachm or two of urine for examination as 
though it were worth a dollar a drop and they could not 
afford more. When a very small quantity of urine is 
thus furnished the specific gravity must be ascertained by 
dilution as follows : take one part of the urine and add 
three parts of distilled water to it so as to make enough 
liquid to fill the cylinder, say two-thirds full, and take the 
specific gravity as before with the urinometer. After ob- 
taining the specific gravity multiply the last figure of it 
by 4 and the result is the specific gravity of the urine ; 
thus if the specific gravity of the mixture be 1005, 
then multiply 5 by 4=20 and 1020 is the specific gravity 
of the urine itself. In other words, multiply the last 
figure of the specfic gravity fouvnd by the total number 
of parts of urine and water. 

Before taking the specific gravity of urine with an 
urinometer see whether the fluid has a temperature of 60° 
JF. or not by dipping a chemical thermometer into it ; if 
it has a temperature of about 60°, simply take the specific 



Tempera- 
ture. 



No. to be 

added to the 

indication. 



60° 


0.00 


61° 


0.08 


62° 


0.16 


63° 


0.24 


64° 


0.32 


65° 


0.40 


66° 


0.50 


67° 


0.60 


68° 


0.70 



Tempera- 
ture. 



69° 

70° 

71° 

72° 

73° 

74 

75° 

76° 



No. to be 

added to the 

indication. 



o 



0.80 
0.90 
1.00 
1.10 
1.20 
1.30 
1.40 
1.50 
1.60 



Tempera- 
ture. 



78° 
79° 
80° 
81° 
82° 
83° 
84° 
85° 
86° 



No. to be 

added to the 

indication. 



1.70 
1.80 
1.90 
2.00 
2.10 
2.20 
2.30 
2.40 
2.50 



gravity, but if has not a temperature of 60°, after taking 
the specific gravity consult the above table of Bird. 



PRACTICAL URINALYSIS. 29 

Urinonieters are constructed for use at a certain temper- 
ature, 60° or 62° F., hence when the urine has a 
temperature other than 60° or 62° the reading -nil not be 
absolutely correct. It will be seen from the table that 
unless the temperature of the urine be 70° or oyer there 
will be only fractions of one decree of difference ; thus, 
suppose on dipping the chemical thermometer into a 
specimen of urine we find its temperature to be 66°. 
Taking the specific gravity with the urinometer we find 
it to be 1030 ; consulting the table we find five-tenths 
corresponding to a temperature of 66°, hence the true 
specific gravity is 1030.5. Suppose now another specimen 
has a temperature of 86° and a specific gravity of 1028 ; 
consulting the table we find 2.5 corresponding to a 
temperature of 86°, hence 1028+2.5 = 1030.5 is the true 
specific gravity. If the urine be of the temperature of 
the surrounding air in' the room its specific gravity will 
be sufficiently correct for clinical purposes without making 
the corrections indicated by the table, provided, of course, 
the room be not of an extreme temperature, hot or cold ; 
if for any particular reason, as in estimation of quantity 
of urea, etc., the accurate specific gravity be desired, the 
table should be used. If the urine be below the temper- 
ature of the room, warm it. 

Estimation of Solids. — To estimate approximately the 
amount of solid matters contained in the urine proceed as 
follows : 1st, collect the urine of twenty-four hours ; 2d, 
measure it in cubic centimeters by means of a flask 
graduated in cubic centimetres ; 3d, divide the amount of 
cubic centimetres found by 1000 and number the result 
(I). Next take the specific gravity of the urine and 
multiply the twx> right hand figures by 2 (Trapp's coef- 
ficient). Multiply this result by the figure numbered (I) 



30 PRACTICAL URINALYSIS. 

above and the product will be the amount of solids (in 
grammes) in the urine of twenty-four hours. If the 
amount be desired in grains instead of grammes multiply 
the amount found in grammes by 15.4. 

EXAMPLE I. 

Amount of urine, 3000 cubic centimetres in twenty- 
four hours. 

3000 -f- 1000 = 3. (I.) 

Specific gravity of urine 1008. 08x2= 16, (last 
two figures of specific gravity multiplied by 2). 16x3 
= 48 (this result multiplied by number found according 
to I.) 

This urine then contains 48 grammes of solids in the 
total amount passed in twenty-four hours ; to find the 
amount in grains multiply 48 by 15. 4 = 739 grains. 

EXAMPLE II. 

Amount of urine, 400 cubic centimetres in twenty- 
four hours. 

4 400 -^ 1000 = 0.4. (I.) 

Specific gravity of urine, 1002. 02 X 2 = 4 (last 
two figures of specific gravity multiplied by 2). 4 x 0.4 
= 1.6 (this result multiplied by number according to I.) 

This urine then contains 1.6 grammes of solids in the 
total amount passed in twenty-four hours; to find the 
amount of solids in grains multiply 1.6 by 15. 4 = 2 4. 6 

grains. 

This method of calculating the amount of solid con- 
stituents may give a result any where from y L- to \ out of 
the way but it will indicate sufficiently correctly any 
marked change in the total amounts from day to day. 

In calculating the amount of solid constituents some 
attention must be paid to the daily amount of food ; thus 



PRACTICAL URINALYSIS. 31 

a litre of soup will add nearly fifteen grammes of solid 
matter to the urine, therefore it is best to ascertain from 
the patient how much of this substance he has taken in a 
day, if any. 

CLINICAL SUMMARY. 

(Physical Characteristics.) 

- Quantity in Twenty-Four Hours. — Possible normal 

range, 800 to 2000 cubic centimetres (1£ to 4 pints, nearly). 

Usual normal range, 1200 to 1400 cubic centimetres 
(21 to 2-J pints, nearly). 

Large persistent increase (over 2000 cubic centimetres), 
suspect (i.) diabetes ; (ii.) certain forms of Bright's disease. 

Temporary increase, after (i.) hysterical paroxysms ; 
(ii.) other convulsive attacks of both sexes. 

Decreased quautity, in (i.) height of all acute febrile 
disorders, (ii.) certain stages of Bright's disease and dropsy, 
(hi.) cirrhosis of liver. 

Color. — Normal range, golden-yellow 7 to amber. 

Pale, after copious drinking (urina potus) also in (i.) 
anaemia and chlorosis, (ii.) diabetes, (iii.) hysteria and 
convulsions, (iv.) convalescence from acute diseases, (v.) 
atonic gout. 

High, in (i.) fevers, acute diseases, etc. 

Abnormally colored, from (a.) disease or (b.) accidental 
constituents. See Part II. 

Odor. — Normal, sui generis, urinous. 

Sweetish,whey-like or like sour milk, in diabetes mellitus. 

Ammoniacal or putrid, decomposed urine ; if so when 
freshly passed suspect cystic troubles. 

Gangrenous, in some forms of Bright's disease. 

Aspect. — If clear not necessarily normal, but if normal 
must be clear. 



32 PRACTICAL URINALYSIS. 

Turbid, when freshly passed, suspect presence of pus, 
mucus, epithelial cells, etc., suggesting cystic troubles. 
Clear when first passed but sedimentary on cooling, 

urates may be present. 

Reaction.— Normal range, slightly acid to neutral or 

alkaline (after meals). 

Strongly acid, in febrile disorders. 

Alkaline, (from fixed alkali) in (i.) anaemia and chlo- 
rosis, (ii.) pulmonary disorders and (iii.) some acute 
diseases. See Part II. 

Alkaline (from volatile alkali), when freshly passed, in 

cystic troubles. 

Specific Gravity.— Normal range, 1015 to 1025. 

High, in febrile states— 1030 to 1040. 

Permanently high in diabetes mellitus— 1030 to 1055. 

Low, when quantity large, (i.) urina potus, (ii.) polyuria 
and certain stages of dropsy. 

Low, when quantity small, certain stages, Bright's dis- 
ease. 

Solids.— Normal amount 55 to 75 grammes (850 to 

1155 grains, nearly). 

Decreased (i.) in acute disease (40 to 50 grammes) or 
(ii.) when quantity of urine abundant hydruria (many 
cases of hydremia and dropsy), (iii.) most chronic dis- 
eases. 

U. B.— Increase of solids of the urine at the height of 

acute diseases usually an unfavorable sign. 
Increased, in (i.) diabetes. 



PRACTICAL UMKALT8ia 33 

ABNORMAL CONSTITUENTS. 

Detection of Albumin. — Albuminous urine is often of 
low specific gravity. 1010 to 1002, is generally turbid and 
apt to retain any foam which forms on its surface. 

Before testing for albumin the urine should be filtered 
if very turbid and the following tests may then subse- 

quently be made : (a.) Take the reaction of the urine 

if alkaline add a few drops of acetic acid, otherwise not 

boil and add an abundant amount of nitric acid : if the 
urine which originally, or after being filtered, was clear. 

* — 

is now turbid, albumin is present. If the urine shows no 
turbidity, after such treatment, take a fresh amount, filter 
it and. (i,) filling a test-tube one-third full allow twenty 
or thirty drops of pure, colorless nitric acid to trickle 
slowly down the side of the inclined tube to the bottom 
of the urine: if a white disc appear above the layer of 

acid, albumin is present, as may be proved bv heating 

urates clear on heating, albumin does not : if there is no 
albumin there will be seen merely a layer of acid at the 
bottom of the tube, above which will rest the urine. In 
heating hold the tube by the closed end and heat that 
portion when turbidity is seen. If albumin be not found 
by tests a and b take a fresh amount of the urine, filter 
it, if necessary, add (c) two drops of acetic acid to, sav. 
half a test-tube full of urine and then pour in some 
solution of potassium ferrocyanide. If even a verv small 
amount of albumin is present a turbidity will be seen. 

The tests a. /,, and c y may readily be made in the 
physician's office but at the bedside of a patient a simpler 
one is desirable, and the following has been su^e-sted bv 
Kaabe : Into about one cubic centimetre of the suspected 

n 4. 

oT 



34 PRACTICAL URINALYSIS. 

urine contained in a narrow test-tube, drop (d) a crystal 
of trichloracetic acid and, without shaking, let the urine 
stand until the crystal has dissolved. If albumin is 
present a distinct turbidity appears at the bottom of the 
test-tnbe in sharp contrast to the urine in the upper part ; 
if urates are present a generally diffused but slight tur- 
bidity may appear which heat will clear ; if the urine is 
very turbid some of it should be decanted, or, if possible, 
filtered. It is well to confirm this test subsequently by 

use of tests a and b. 

If a patient has been taking drugs containing a resin, 
such as cubebs, copaiva, sandal-wood, turpentine and the 
like, test a on being applied may produce a turbidity in 
the urine which is not due to albumin. In this case add 
alcohol, and the turbidity, if due to a resin, will be cleared, 
but if due to albumin will not be affected. 

Some forms of albumin may be encountered in the urine 
which test a will fail to detect ; in this case test I is of 

service. 

Estimation of the Quantity of Albumin.— The following 

is a rough but useful approximate quantity test : Boil a 

given quantity of the urine in a test-tube— with a drop 

or two of acetic acid, if alkaline; set aside for five or 

six hours. The precipitated albumin sinks and forms a 

layer of varying thickness. The proportion of albumin is 

estimated by the depth of this layer as compared with the 

height of the column of urine and may be expressed in 

numbers as |, \, T \, etc. If too little albumin is present 

to form a layer, call it "cloudiness" or "opalescence." 

The urine should first be filtered and a graduated tube 

used if possible. 

Dr. Wm. Eoberts estimates albumin by dilution, as fol- 
lows : Take a clear glass jar capable of holding 2000 or 



PKACTICAL URINALYSIS. 35 

or 3000 cubic centimetres of fluid; into this place five 
cubic centimetres of the albuminous urine and dilute it 
with five cubic centimetres of clear water. This dilution 
may be termed the ^first degree" ; add to it some nitric 
acid, a few drops. If cloudiness occurs, again add 
another five cubic centimetres of water, and again, if 
necessary, test with nitric acid ; this second dilution forms 
the "second degree." And continue in this manner until 
the acid occasions no reaction after the liquid has stood 
for thirty seconds, but occasions a faint opalescence at the 
forty-fifth second ; this is the zero point of the reaction. 
Now divide the number of the dilutions or degrees re- 
quired by 5 (the number of cubic centimeters of urine 
used to start with), which will give "the degrees of 
albumin" each degree of which he has ascertained by 
calculation to be an indication of .0034 per cent of 
albumin in the urine tested. Suppose 1200 cubic centi- 
metres of urine to be passed in the twenty-four hours, five 
cubic centimetres of which required 1250 dilutions before 
the zero reaction was attained ; then 125 0-^-5 = 250x 
.0034 = .85 per cent of albumin ; 1200 cubic centimetres 
multiplied by .85 equals 10.2 grammes of albumin in this 
urine of twenty-four hours. 

Detection of Blood-Extractives. — If tincture of galls be 
added to urine and a precipitate immediately occur the 
presence of blood-extractives is indicated. • 

Detection of Sugar. — If the urine contain a plentiful 
amount of sugar a simple and convenient clinical test is 
the following : Add an equal amount of a freshly-made 
solution of potassa (specific gravity 1060) to the urine 
and holding the lower closed end of the test-tube between 
the thumb and forefinger heat the urine in the upper part 
of the tube to boiling ; if sugar be present the heated 



36 PRACTICAL URINALYSIS. 

portion will be colored yellow, then brown-red (or even- 
dark purple if a large quantity of sugar is present), while 
in the non-heated part of the tube the urine does not 
chano-e its color. Addition of a little nitric acid causes 
an odor to be given off somewhat resembling that of 
molasses. A whitish, flocculent precipitate of phosphates 
should not be mistaken for a reaction of sugar, in applying 
this test In case the above test give an unsatisfactory or 
doubtful result the practitioner should by all means try 
Fehlino's test liquid or some of its modifications ; that 
used by Prof. Haines is a perfectly stable preparation and 
if the physician be so situated as to be able to procure the 
ingredients and prepare the solution he had far better 
confine his attention to it without trying the first test 
given above. Haines's formula is as follows : 

Pure sulphate of copper, - - - - grains, 30 
Pure glycerine, - - - - fluid drachms, 2 
Pure caustic potash, in sticks, - drachms, 1* 

Pure water, fluid ounces, 6 

Dissolve the sulphate of copper and glycerine in a por- 
tion of the water and the caustic potash in the remainder ; 
mix the two solutions, when a perfectly clear, transparent, 
dark-blue liquid should result, which may be bottled and 
set aside for use. After a week or two a slight reddish 
deposit may appear which, however, does not affect its 
value as a test ; in using, simply decant the clear liquid 
from the sediment. In preparing the solution if pure 
caustic potassa in sticks cannot be easily obtained, use 
instead 31 fluid ounces of the officinal liquor potass*, 
reducing the quantity of pure water to ?£ fluid ounces, 
the other ingredients remaining as above. To test for 
sugar take a fluid drachm or two of the test solution and 
<rentlv boil it when no change should take place ; now add 



PRACTICAL URINALYSIS. 37 

six or eight drops of the suspected urine and again heat 
to the boiling point. If sugar be present an abundant 
yellow or yellowish-red precipitate will be thrown down ; 
if sugar is not present no such precipitate appears but the 
color of the test solution will be rendered somewhat lighter 
and often of a greenish or even of a greenish-yellow shade 
by the dilution of the blue test liquid with the yellow urine. 
A white flocculent deposit of phosphates from the urine 
used should not be mistaken for a reaction of sugar. 

If any one be perplexed by the deposit of phosphates 
and the change of color produced by dilution of yellow 
urine with the blue test liquid he is recommended to try 
the following method of procedure which although rather 
long and tedious, leaves little room for doubt : Dissolve 
34.64 grammes pure crystallized sulphate of copper, free 
from iron and moisture, in 200 cubic centimetres of dis- 
tilled water. 173 grammes of Kochelle salt are next 
dissolved in 480 cubic centimetres of caustic soda solution 
(specific gravity 1.14) and to it the copper solution 
previously made is added, and the whole diluted with 
distilled water to exactly one litre. Heat to boiling, in 
a good sized test-tube, 10 cubic centimetres (2.7 fluid 
drachms) of the solution, previously introducing a few 
small fragments of clay tobacco-pipe to prevent bumping, 
i e., spasmodic boiling. When boiling add | to 1 cubic 
centimetre (8 to 16 drops) of the urine which has been 
previously treated as follows : Albumin, if present, removed 
by heating the slightly acid or acidified urine to boiling 
and then filtering from any precipitate. Next (or — if 
the urine contain no albumin— -first,) rendered distinctly 
alkaline by addition of caustic soda solution, filtered from 
any precipitate of phosphates, etc., and finally added to 



38 PRACTICAL URINALYSIS. 

the boiling Fehling solution, in amount £ to 1 cubic 
centimetre, as specified above. 

If sugar be abundant as in a decidedly diabetic urine, a 
yellowish or brick-red opacity and deposit will be produced. 
If a doubtful reaction is obtained, test for traces of sugar 
by adding 7 or 8 cubic centimetres of the urine to the hot 
liquid, heating again to ebullition and then setting the 
tube aside for some time. If no turbidity is produced as 
the mixture cools, the urine is either free from sugar or 
at any rate contains less than 0.025 per cent. If the 
quantity of sugar present is small— that is under 0.5 per 
cen t_the yellow or red precipitate does not take place 
immediately, but occurs as the liquid cools, the appearance 
being somewhat peculiar. The liquid first loses its 
transparency and passes from a clear bluish-green to an 
opaque, light-greenish color. This green, milky appear- 
ance is quite characteristic of diabetic sugar. 

The test given above is recommended by Allen, of ' 
Sheffield ; several circumstances must be noted in applying 
it : I. Fehling's solution, made as described, undergoes 
certain obscure changes on exposure to air and light, 
hence it is better to prepare this solution in two parts, 
namely (a) 500 cubic centimetres of the Kochelle salt 
solution and (b) 500 cubic centimetres of the sulphate of 
copper solution. This may be done by adding water to 
each solution separately until each amounts to 500 cubic 
centimetres, rather than adding enough water after the 
two have been mixed, to make 1000 cubic centimetres or 
1 litre, as directed previously. Instead, therefore, of 
mixing the copper sulphate solution and the Kochelle salt 
solution keep them in separate bottles and mix in equal 
volumes only when used. Thus, if according to direction 
10 cubic centimetres of Fehling's solution are required, 



PEACTICAL URINALYSIS. 39 

add 5 cubic centimetres of the copper solution to a 
like amount of the Eochelle salt solution. II. Much 
of the Eochelle salt of commerce is impure ; the safest 
method of preparing it is as follows: Dissolve com- 
mercial cream of tartar in hot water, adding carbonate of 
sodium till the liquid remains slightly alkaline after boil- 
ing, filtering from the precipitated calcium carbonate and 
crystallizing the Eochelle salt from the clear liquid. III. 
Too much importance must not be laid upon detecting 
traces of sugar since normal urine often contains small 
amounts of this substance. 

Estimation of Sugar. — The simplest method of de- 
termining the quantity of sugar in urine is the " differential 
density fermentation test" which is performed as follows : 

a. Pour four fluid ounces of urine into a twelve ounce 
bottle ; 

b. Next add a lump of German (condensed) yeast the 
size of a chestnut ; 

c. Find a cork that does not fit the bottle well and 
loosely cork the bottle with it ; 

d. Set the bottle in a warm place ; some authors suggest 
the " mantle-piece," evidently forgetting that the rage for 
bric-a-brac has somewhat subsided ; 

e. Now find another twelve ounce bottle and pour into 
it four fluid ounces of the same urine ; 

/. Find a cork that fits it very tightly, cork and set 
side by side with loosely corked bottle "No. 1," being 
careful not to add any yeast to tightly corked bottle, No. 2 ; 

g. Next allow twenty-two hours to elapse and then 
remove both bottles to a cool place and let them rest two 
hours more ; 



40 PRACTICAL URINALYSIS. 

h. Procure two beakers or cylindrical vessels and at the 
expiration of the two hours pour the contents of bottle 
No. 1 into one beaker and those of No. 2 into the other ; 
i. Take the specific gravity of each with the urinometer ; 
the specific gravity of the urine in bottle No. 1 will be 
less than that of the urine of bottle No. 2, owing to 
fermentation in No. 1 caused by yeast, having changed 
the sugar into alcohol and carbonic acid; the latter 
substance, being a gas, escapes ; 

j. Subtract the specific gravity of the urine of bottle 
No. 1 from the specific gravity of the urine of bottle No. 2, 
and the difference is grains of sugar to the fluid ounce of 
urine. 

For instance, suppose the specific gravity of the urine 
in bottle No. 1 is 1020, and that of bottle No. 2, 1040; 
1040 less 1020 equals 20. This signifies that the urine 
contains 20 grains of sugar to the fluid ounce of urine ; 
the urine for twenty-four hours, of which the urine ex- 
amined has been a sample, having been measured is, say, 
100 ounces; then 100 X 20 will give the total amount 
of sugar in grains for the twenty-four hours, viz., 2000 

grains. 

Detection of Albumin and Sugar when together.— 

When it is desired to test urine for sugar, which is sus- 
pected, or has been found to contain albumin, proceed as 
follows : Take the reaction, and if alkaline, add a drop 
or two of acetic acid — otherwise not — boil thoroughly 
and the albumin will be precipitated. Let the urine re- 
main at rest until the albumin has settled to the bottom 
of the tube, then pour off carefully the supernatant urine 
and test it for sugar by any of the methods previously 
mentioned. 



PRACTICAL URINALYSIS. 41 

Detection of Bile Coloring-Matter. — Fill a test-tube 
half or two-thirds full of urine and allow 20 or 30 drops 
of red nitric acid (commercial nitric acid which has been 
exposed to the sun's rays) to trickle slowly down the side 
of tube held inclined. At the juncture of the urine with 
the acid a play of green and blue colors will be seen, 
especially if the tube be held before some white object, 
as the wall. 

CLINICAL SUMMARY. 

(Abnormal Constituents.) 

Albumin. — A notable amount of albumin occurs in the 
urine of (i.) many acute diseases, (ii.) Bright's disease, 
(iii.) pregnancy and the puerperal state, (iv.) after the 
administration of, and in poisoning by, various drugs. 

a In cases of pregnancy where albumin is found in the 
urine examine the deposit with the microscope for casts 
and other evidences of renal disease — mere presence of 
albumin without casts, etc., is not necessarily alarming. 

b. A pale, dilute urine abundantly albuminous is more 
indicative of Bright's disease than a dense high-colored 
urine with less albumin ; the latter is more apt to be 
indicative of pyrexia or some impediment to the circula- 
tion. In cases of suspected Bright's disease observe (i.) 
quantity of urine in twenty -four hours, (ii.) albumin, (iii.) 
tube casts, epithelia, etc., in the deposit, using the micro- 
scope. 

c. In diphtheria, albumin may be found in the urine 
early in the course of the disease. 

d. If the urine contains pus, blood, spermatic fluid or 
leucorrhoeal discharge, then albumin corresponding to the 
same, may be found. 

Sugar. — Sugar persistently present in the abundant urine 



42 PRACTICAL URINALYSIS. 

of high specific gravity, in connection with the well-known 
symptoms of hunger, thirst, emaciation, etc., indicates 
diabetes mellitus. 

Albumin and Sugar together. — Found in (i.) glycosuria, 
(ii.) diabetes mellitus, (hi.) chyluria. 

Bile. — The presence of bile coloring-matter in the urine 
is of slight clinical importance ; it may be found in the 
urine of (i.) icterus, (ii.) phosphorus poisoning, and (hi.) 
after severe burns. 

Extractive matters — Presence of blood-extractives in 
the urine shown by immediate precipitate with tincture of 
nut-galls may be found (i.) in Bright's disease — before 
appearance of albumin and after its disappearance, (ii.) 
irritation from renal calculus before albumin, blood or 
pus, etc., have appeared. 



DEPOSITS. 

Beale divides deposits into three classes : 

I. Light, flocculent, transparent, voluminous deposits 
— mucus and epithelium, spermatozoa, vibriones, fungi, 
casts. 

II. Dense, opaque, bulky — urates, pus, phosphates. 

III. Granular or crystalline, small bulk, sinking to 
bottom or deposited on sides of the urine glass — uric acid, 
calcium oxalate, triple phosphate, cystin, lime carbonate, 
blood corpuscles. 

N. B. — A very thick, glairy, gelatinous deposit is pus 
altered by the action of ammonium carbonate in the 
decomposing urine. 

Method of Recognizing the Constituents of a Deposit. — 
Ascertain as nearly as possible to what class (mentioned 



PRACTICAL URINALYSIS. 43 

above) the deposit belongs, next apply chemical tests and 
verify with the microscope if necessary. 

Non-Organized Deposits. 

Recognition of an Urate Deposit. — Let the urine settle, 
pour off the supernatant liquid, pour some of the sedi- 
mentary urine at the bottom into a test-tube, heat (not to 
boiling, lest any albumen present be precipitated,) and if 
the urine clears the presence of a urate deposit is indicated. 
Stand the test-tube aside and if on cooling the urine 
becomes turbid again the correctness of the conclusion is 
verified. The practitioner sometimes mistakes urates for 
albumin ; urates are a deposit in the urine clearing on the 
application of gentle heat — albumin is never a deposit in 
urine but coagulated by heating to nearly the boiling 
point ; in other words, gentle heat causes the urates to 
disappear, boiliug heat, albumin to appear. Suppose then 
the urine contains a sediment of urates and albumin — 
gentle heat will cause the urate deposit to disappear and 
the urine to become comparatively clear, but further 
heating will now cause a turbidity due to the presence of 
albumin, and on boiling the urine will become persistently 
cloudy. The microscope is not indispensable for the 
recognition of urate deposits as distinguished from others, 
but it is worth while to know whether the urates them- 
selves are amorphous (non-crystalline) or crystalline. If 
a deposit, w T hich by chemical means has been ascertained 
to contain urates, be examined with the microscope the 
appearance, if the urates be amorphous (non-crystalline), 
is that of irregular particles or granular powder ; in rare 
cases the so-called " hedge-hog" crystals of sodium urate 
may be seen (Fig. 7). If seen in stale urine prismatic 



44 



PRACTICAL URINALYSIS. 



crystals arranged in star-like masses may be noticed, 
which are of no clinical import. 

Recognition of an "Uric acid Deposit. — Urine depositing 
uric acid has usually a rich yellow or orange color and 
invariably an acid reaction. Uric acid crystals are often 
visible to the naked eye, forming a film on the surface of 




Fig. 7. 

the urine or lying scattered like brown specks on the sides 
of the glass, eventually subsiding into a dense red deposit 
resembling cayenne pepper. Urates are often associated 

with uric acid. 

Chemical Detection. — Heat (not to boiling) a little of 
the deposit in a test-tube, and if it clears either partly or 
wholly urates are present; to any residue add liquor 
potassse and again heat gently, if any or all dissolves 
uric acid is present. In applying this test it is desirable 
to separate the deposit from the urine either by careful 
decantation or by filtration, as liquor potassae and heat 
will throw down earthy phosphates normally present in 
urine if any of the latter be present in the tube; the 
microscope affords a more rapid method of identifying an 
uric acid deposit. 

Microscopical Appearances. — The distinctive feature of 



PKACTICAL URINALYSIS. 



45 



uric acid crystals is their color which may be red, yellow 
or brown, unless by some chance they have been broken 
or crushed when the fragments may have a whitish 
appearance. The higher the color of the urine the darker 




Fig. 8. 



the crystals, and vice versa ; if the urine be of any ab- 
normal color, as blue or black, the uric acid crystals will 
be the same. Use a low power, say 100 to 200 diameters, 
and four-sided rhombs or "blocks" will be seen, or some- 
times hexagonal plates ; occasionally when seen on certain 
surfaces they may take the form of large stars or daggers. 
Fig. 8 shows the common forms which uric acid crystals 
may assume and Fig. 9 the rarer. 

Recognition of an Oxalate of Lime Deposit. — Urine 
depositing oxalate of lime may be (i.) high colored, or 
(ii.) of a pale greenish color, according to the conditions 
present. The deposit itself may be very scanty, colorless, 
and verv like a mucus " cloud." The form of the crystals 



46 



PRACTICAL URINALYSIS. 



is so characteristic that no chemical test is necessary, the 
rise of the microscope sufficing. Oxalate of lime does not 
dissolve in strong acetic acid and in this way may be told 
from the phosphates. It is insoluble in liquor potassae and 
thus differs from uric acid. 




Fig. 9. 

Microscopic Appearances. — The crystals are very small 
requiring a power of from 400 to 600 diameters to show 
them well, although any one familiar with them can detect 
them with a lower power. Their appearance is that of 
the rear of a letter envelope (Fig. 10) or sometimes that 
of a dumb-bell. They are, in the former case, octahedral 
in form, and very transparent; hence the focussing is 
sometimes difficult. They may be more readily detected 
by moving the slide so that the edge of the cover comes 
in to the centre of the field ; then focus clear and move 
the deposit. To produce lime oxalate crystals artificially 
add to the urine a little lump of oxalic acid and after a 
few hours examine with the microscope. 

Recognition of a Phosphatic Deposit.— Urine containing 
a deposit of phosphates is usually of an alkaline or at 
most feebly acid reaction; its appearance is often 
" milky," and on standing, the whitish deposit settles to 



PRACTICAL URINALYSIS. 



47 



the bottom of the urine glass and does not increase as 
the urine cools. Urate deposits are sometimes of so light 
a color as to be mistaken by the eye for phosphatic sedi- 
ments. 




Fig. io. 

A. — Octahedral crystals of oxalate of lime. B. — The same when dry. C. — Do- 
decahedral crystals of lime. D.— Dumb-bells— oxalurate of lime. E.— Oval forms 
of oxalurate of lime. — King. 

Chemical Detection. — Heat the deposit from which most 
of the urine has been decanted and it does not dissolve ; 
add a drop of nitric acid and it is dissolved. 

Microscopical Appearances. — Obtain a drop from the 
bottom of the urine glass in which the deposit has settled 
and place upon a slide ; if the urine be pale and faintly 
acid possibly the " stellar " phosphate (crystalline calcium 
phosphate) may be present (Fig. 11). This deposit, how- 
ever, is not a common one. 

Usually the amorphous or no n -crystalline calcium 
phosphate may be seen in such w T hitish deposits occurring 
in the form of granules, roundish or oval, with dark out- 



48 



PRACTICAL URINALYSIS. 




Fig. ii. 



Urinary deposits consisting of crystals of phosphate of lime, octahedra of oxalate 
csf lime with a little mucus (215 diameters).— Beale. 

lines, isolated, or else three or fotir united in a star-like 
form or in beads, etc. ; more often this phosphate shows 
very pale, small, transparent globules, hard to see, and 
always united by irregular punctated patches. 

The latter form is the more common appearance ; a 
drop of acetic acid will dissolve both forms of the 
amorphous calcium phosphate (Fig. 12 d). 

Ammonio-magnesium phosphate is very easily recog- 
nized ; it occurs as very large, transparent crystals with 
sharply-defined edges, generally isolated and having the 
typical form of a triangular prism with beveled edges, 
found only in alkaline urine and soluble in acetic acid 
(Fig 12 a). 



PRACTICAL URINALYSIS. 



49 



It must be remembered that a deposit of phosphates 
does not necessarily indicate excess of the same but merely 
diminished acidity of the urine. 




Fig. i2. 

A— Prismatic crystals of triple phosphate. B— Penniform crystals of triple phos- 
phate. L— btellar and foliaceous crvstals of triple phosphate. D— Mixed Shos 
phates ; amorphous phosphate of lime. F 

A few drops of solution of sesquicarbonate of ammonia (one drachm of the salt 
to one fluid ounce of distilled water), added to urine passed after the dieestion 
of a meal, will precipitate the neutral tr pie phosphate.— (King). 

Detection of Fat in the Urine.— Chylous urine has a 
milky, turbid and opaque appearance due to presence of 
fatty matter. Upon standing for some time a tremulous 
coagulum occurs succeeded by flakes, the fatty matter 
floating like cream on the surface. [Add ether to the 
urine, mix gently, the fatty matter is dissolved and the 
urine assumes its natural color and transparency. If the 
ether be drawn off with a pipette and evaporated it will 
yield a yellowish fat, solid or fluid]. Oil globules are 
rarely to be seen with the microscope since the fat is 
4t 



50 PRACTICAL URINALYSIS. 

present in molecular form ; with high powers, 450 diame- 
ters and upward, fatty particles may be seen. 

Fatty globules present in renal casts will be hereafter 
noticed. Fat or oil globules, themselves, are easily identi- 
fied by the microscope if not dissolved by other constituents 
of the urine ; they present the form of smooth, roundish, 
flattened discs, or if compressed are polyhedral in form ; 
they strongly refract light which gives them a sharp, dark 
outline with transmitted light and with reflected light a 
whitish centre and a shining silvery outline. 

To practice identification of fat in the urine agitate 
strongly some fresh urine with a little milk and then 
examine a drop with the microscope. 

CLINICAL SUMMARY. 

(Non-Organized Deposits.) 

Deposits of Urates and Uric Acid.— These are found in 

I. Normal urine in winter ; if occasional, A 
of no clinical significance. 

II. Extensive cutaneous diseases as eczema, 

psoriasis. 

III. Forms of dyspepsia associated mm 

irregular secretion of gastric juice. 

IV. Normal urine in summer; if occa- 
sional, of no clinical significance. 

V. At the height of febrile disorders, 
especially rheumatism, and in diarrhoea. 

VI. Alternating with sugar in the urine. _ 
In these diseases uric acid is not necessarily in excess 

but changes in the acidity of the urine cause it and the 
urates t<Tbe deposited. Excess of uric acid and urates is 
found in the urine in the following diseases : 

I Diseases of the liver as acute yellow ) J c r t e h a e s r e 
atrophy, cirrhosis and cancer ; also in scurvy. \ constituents. 



V 



Absolute 

increase in 

acidity ot 

the urine. 



Relative 
increase in 
acidity of 
the urine. 



. Increase 
of other 
constituents. 



PRACTICAL URINALYSIS. 51 

II. Functional derangements of the liver, 
especially when too much animal food is 
ingested. 

III. Antecedent conditions to the de- L 
velopment of phthisis, cancer or sometimes f 
diabetes ; preceding the outbreak of such 
constitutional conditions as scrofula, syphilis, 
and of gout in its early attacks. 

Although uric acid and the urates be in excess in the 
urine they may not be found as a deposit. 

If a deposit of uric acid occurs before the urine cools, 
or immediately after, the formation of gravel or stone is 
to be dreaded ; if the deposit occurs three or four hours 
after the urine is passed, gravel and stone are not so much 
to be dreaded; if the deposit occurs twelve to twenty 
hours after the urine is voided when acid fermentation 
has set in, it is perfectly normal. 

Deposits of Oxalate of Lime. — These mav be due to 

i- 

I. Physiological causes : a. Derived directlv from the 
food by the ingestion of substances containing oxalate of 
lime, as rhubarb, etc. i. Derived indirectly from the food 
by incomplete oxidation of the sugars, starches, and fats. 
Eegulation of diet, change of air, etc., improve the con- 
dition. 

II. Pathological causes : a. Many disorders of the liver, 
heart and lungs — high-colored uriue. b. Spermatorrhoea. 
c. Cases of dyspepsia to which the term "oxaluria" is 
given owing to the persistency of the oxalate deposit — 
lio'ht colored urine. . 

A coustant, large deposit of oxalate of lime renders the 
formation of oxalate of lime (mulberry) calculus possible. 

Deposits of Phosphates. — These are due to an alkaline 
or neutral reaction of the urine and may be found : 



g£ PRACTICAL URINALYSIS. 

I. Normally after a meal or after partaking of fruit, 
carbonates, citrates, or acetates. 

II Abnormally in various conditions : a. If the deposit 
be seen daily and be amorphous, i. e., contain no crystals, 
n0 Lg of "great moment is indicated ■**"££ 
exhaustion, as from severe study or loss of sleep J the 
deposit be crystalline and no diet rich in hnie at the ^ ame 
time be taken, diseases of the s^nal-cord and eh, n 
twtori affections are indicated ; especially is this the case 
if the crystals be those of ammonia-magnesium phosphate 
itriple phosphate. If triple phosphate be persistently 
deposited in the comparatively fresh urine there is reason 
tTar formation of calculus. Crystals of triple phos- 
phate occurring in stale urine when not found m tresh 
are of no clinical significance. 

Fat in the TJrine.-Found in (i.) chyluna-ui me con- 
taining chvle, (ii.) fatty degeneration of some part of the 
S apparatus, (hi.) constitutional affections assod- 
ated with marked cachexia as phthisis, pyaemia, etc. 

Organized Deposits 

Chemical Detection of Blood in the Urine Fill a bottle 
two-thirds full of spirit of turpentine, cork it oo ely and 
expose it to the light for several weeks ; kept in this way 
Xomes well ozonized. When the test for blood is to 
be made take equal parts of this ozonized spirit and L o 
tincture of guaiac, say two cubic centimetres about half 
a drachm) of each, mix and shake thoroughly m a test- 
tube when an emulsion is formed. Next, let about an 
equal quantity of the urine to be tested trickle down the 
ide of the teltube, held inclined, and let it stand a few 
moments. If blood be present in the urine a bluish ayer 
Xppear at the Juncture of the urine and the emulsion, 



PRACTICAL URINALYSIS. 



53 



that is, about in the middle of the whole — (Alnien's test). 
If blood is not present a layer of a dirty yellow color is 
seen. If the tincture of guaiac be dilated with three or 
four times its bulk of alcohol this test becomes a very 
delicate one, detecting even small traces of blood. 

Use urine freshly passed for both chemical and micro- 
scopical examination when blood is to be looked for. 

Microscopical Appearances of Blood. — If the urine is 
acid and of average specific gravity, say 1020 to 1025, 
the blood corpuscles will be visible and shapely for seA-eral 
davs, but when the urine is ammoniacal especially if it be 
of low specific gravity, they speedily disappear, in which 
case the blood coloring matter must be tested for chemi- 
callv. 




FlG. 13. — BLOOD- CORPUSCLES IN URINE. 

a, slightly distended by imbibition; b, showing their bi-concave contour 
c, shrivelled; d, serrated. — Roberts. 



To understand the appearance of blood in the urine 
first study that of blood drawn from a blood-vessel, i. e., 



54 PRACTICAL URINALYSIS. 

"normal" blood; the microscopical appearance of blood 
itself is that of globules or corpuscles without nuclei, 
smooth, flat, non-granular, yellow or reddish-brown and 
either detached or adhering in rouleaux. The discs being 
bi-concave a change in focussing will give a dark circum- 
ference and a light centre or the reverse ; if the fluid 
containing them be set in motion the bi-concave form will 
be at once observed. Having learned the appearance of 
the blood drawn from a blood-vessel next observe that 
occurring in urine (Fig. 13). 

In acid urine, as has been observed before, blood-cor- 
puscles retain their characteristic form for a long time; 
one point must be noticed and that is that blood-corpuscles 
in the urine are separate and sharply defined and do not 
run into rouleaux or rows like those of blood drawn from 
a blood-vessel, except in profuse haemorrhages from the 

bladder. 

They exhibit, however, small discs showing a central 
shadow corresponding to the depression, and if standing 
on their edges they appear bi-concave. They appear 
reddish with a slight greenish tinge, i. e., paler than the 

normal. 

So much then for the appearance of the blood cor- 
puscles in acid urine of a specific gravity not far from 
1028, that of blood serum itself. In case blood be 
sought for in such urine the practitioner can easily 
compare the microscopical appearances with those of a 
drop of blood drawn from his hand by the prick of a 
needle. If the blood remains in such acid urine for 
several days its corpuscles may become somewhat notched 
or indented, thus differing from normal blood corpuscles. 

The form of the corpuscles undergoes many changes 
coincident with those of the urine, and when they are in 



PRACTICAL URINALYSIS. 55 

watery urine (specific gravity 1010 or less) the description 
given above will not apply. 

In such urine of low specific gravity, the corpuscles 
imbibe enough water by endosmosis as to swell visibly, to 
become bi-convex instead of bi-concave, and then even 
spherical, losing their color from the exosmosis of coloring 
matter to such an extent that the busy practitioner will 
lose considerable time in trying to identify them unless 
he have a very superior or powerful lens. 

Urine of low specific gravity containing blood is apt to 
become alkaline and decompose very soon, and then the 
blood-corpuscles are no longer recognizable. In order to 
identify blood-corpuscles with ease, the urine should be 
acid in reaction, of a specific gravity of between 1020 and 
1028, and fresh. 

To examine the urine microscopically for blood let it 
stand for a time until any turbidity may have at least 

%J %j w 

partially settled, then introduce a pipette well into the 
lower part of the glass and obtain a drop of urine which 
convey to a glass slide and drop there, place the same 
under the microscope, focus carefully to suit the eye. If 
a low power is used the red corpuscles may be confounded 
with spores of certain fungi; high power will show a 
nucleus in such spores but none in red blood -corpuscles. 

If any uncertainty exist in the mind let the urine stand 
a few days when the spores aforesaid, if any, will germin- 
ate or bud, a habit to which red blood-corpuscles are not 
addicted. 

It is sometimes difficult to distinguish red blood-cor- 
puscles from the nuclei of renal epithelium except by 
their feeble refractive power and less coloration from 
ni amenta solution. 

In general, especially if the urine be of acid reaction, 



56 PEACTICAL UKINALYSIS. 

average specific gravity, and recently passed, the following 
description will lead the hurried physician to recognize 
the red blood-corpuscles under the microscope : 

" Circular discs or globules ; non-nucleated ; -g-^j- inch 
in diameter ; separate ; edges smooth or dentated ; trans- 
parent or of a faintly yellowish color ; sometimes presenting 
a central depression, and if seen in profile, with a high 
power, bi-concave. If a drop of acetic acid be added they 
swell or shrink and present a ' raspberry' aspect." 

If with Almen's test the blue coloration has been 
obtained and with the microscope blood-corpuscles are 
identified, haemorrhage from some part of the urinary 
apparatus is indicated. In applying Almen's test be sure 
that the lower strata of urine are examined. In urine of 
high specific gravity the blood-corpuscles frequently 
contract, shrivel, and become distorted, indented or 
"crenated" from exosmosis, so that their microscopical 
identification is not easy. 

Detection of Pus in the Urine. — To detect pus in the 
urine by chemical means is not always easy, being in some 
cases impossible. Urine containing pus is milky and 
turbid when voided, sometimes acid but generally alkaline, 
is light colored, even whitish, and has the peculiarity of 
clearing on standing ; for instance, if a bottle of turbid 
urine of light color is brought you and after letting it 
stand a few hours it is noticeably clear, examine the dense, 
opaque, yellowish-white sediment at the bottom of the 
bottle for pus. 

To do this chemically, first heat a little of the mixed 
urine and deposit, and if it does not clear, carefully 
drain off all the urine possible without losing any of the 
deposit ; which is conveniently done by holding a glass 
rod to the lip of the bottle and pouring the urine slowly 



PRACTICAL URINALYSIS. 57 

- that ir will trickle down the rod. Then to the deposit 
left in the bottle add a small piece of solid potassium 
hydrate and stir some ruinates with a srlass rod. If the 
sediment con-:-: of pus it will lose its white color, becom- 
ing greenish and glassy, at first thready, finally more 

mpact, viscous, and stringy, the latter quality being 
readily noticed if one attempt to pour it from one vessel 

another. Mucus treated hi the same manner becomes 
a thin liquid with flakes. If the amount of pus is small 
the sediment will disappear and a thready, gluey liquid 
result. It is advisable to obtain the sediment as free from 
urine as possible, hence, after carefully decanting the 
urine which has st :-od for some time, pour the residue into 
a tall cylindrical vessel and in turn allow th:s : settle 
removing supernatant urine gently with a large pipette : 
in this way a maximum amount of sediment and a mini- 
mum amount of urine is ::ined without filtering 

The above test is of value only when the urine is acid, 
or neutral in reaction and fresh : in strongly alkaline 
urine, pus, if occurring, is changed by the action of the 
ammonium carbonate formed, into the same gluey, tena- 
cious mass described above. When, therefore, a glairy, 
ropy deposit is found in urine of alkaline reaction, filter, 
and examine the filtered urine for albumin, being careful 
to notice the slightest turbidity. If albumin be found 

en in very small amount we may infer :he presence of 
pus which, as is well known, contains albumin. 

JJicroscopical Appearances* — If the urine be acid or 
neutral examine the sedh: _: with a power of from 300 
to 400 diameters, and a number of spherical, cellular 
bodies about one-third larger than red blood- corpuscles 
may be found (Fig. 14). They may be com: 1 with 
laudable pus from any suppurating wound or abscess. 



58 



PRACTICAL URINALYSIS. 



If the urine is of high specific gravity the pus-corpuscles 
will look smaller and more crumpled than when the urine 
is watery and of a low specific gravity in which they 
appear expanded and clear. A drop of acetic acid placed 
under the cover glass will cause the nuclei to appear 

the red blood-corpuscles have no nuclei — and cause 

the granulations to disappear giving rise to residues of 
various forms and groupings ; on further treatment with 
ammonia the nuclei will disappear and the pus assume a 
viscous consistency which mucus never, under similar 
circumstances, acquires. Pus-corpuscles (Fig. 14) can 




Fig. 14. — pus CORPUSCLES. 
a, without reagents ; b, after the addition of acetic acid.— Roberts. 

not be distinguished, microscopically, from mucus-cor- 
puscles as regards form, etc. When the urine is alkaline 
the form of the pus-corpuscle is so changed as to be 
unrecognizable although occasionally leucocytes may be 
found in the upper part of the deposit together with 
crystals of triple phosphate, the organisms known as 
vibriones and filaments of fungi on their way to develop- 
ment. See Part II. 



PRACTICAL URINALYSIS. 59 

The finding of albumin in the filtered urine, must then 
be resorted to by chemical meaus in order to verify, if 
possible, our idea, that the grayish, viscid, tenacious mass 
contains pns. 

Recognition of Mucus in a Deposit. — Mucus is often 
present in considerable amount in the urine without caus- 
ing any turbidity. Urine containing an abundant amount 
of mucus filters very slowly, and if, after filtration, the 
filtering paper be dried, it will be found covered with a 
glistening "varnish" of mucus adhering to its sides. 

1. Chemical Tests. — To ascertain whether the urine is 
charged with mucus when apparently clear, add to the 
freshly voided urine some acetic acid ; if a considerable 
turbidity appear, which is cleared upon addition of hydro- 
chloric acid, mucus in considerable amount is present. 

xJ. When a plainly visible sediment is present in the 
urine causing one from its appearance to suspect mucus, 
test the supernatant fluid for albumin, and to a little of 
the sediment add a few drops of liquor potassse ; if no 
albumin be found and the addition of the potassa to the 
sediment render it a thin, flaky liquid, it is mucus and 
not pus. The urine should be that freshly voided. 

Microscopical Appearances. — Examine the desposit col- 
lected in the usual manner with a high power, 450 to 500 
diameters. Mucus thus examined shows (i.) epithelial 
cells, (ii.) mucus-corpuscles (iii.) various substances, as 
urates, uric acid, phosphates, fatty droplets, etc., etc. 

It is desirable to identify the mucus-corpuscles in ex- 
amining a deposit for mucus alone ; these are identical 
with pus-corpuscles. If a drop of acetic acid be added to 
the drop of sediment under examination the nucleus of the 
mucus-corpuscles will be plainly seen, and pale, delicate, 



60 



PRACTICAL URINALYSIS. 



finely fibrillated, or punctated, bands or threads sometimes 
tortuous, and frequently anastomosed appear (Fig. 15). 
This fibrillated substance is mucin precipitated from the 
mucus by the acid. It is difficult to distinguish mucus 
from pus microscopically, but if mucus-corpuscles be 
found, test the urine for albumin and treat the deposit 
with liquor potassse as before described. 






© 



^>- 



s> 



© 



Fig i5- 

Recognition of Epithelium in a Deposit — The micro- 
scope must be used for this purpose. Epithelial cells 
found in the urine are of various forms best shown by 
Figs. 16 and 17. It is not always easy to tell just where 
epithelial cells have come from, but the following table 
may serve as an "approximate guide" : 



r 



1. Round or oval 
epithelial cells, 
a little swollen. 



Very large, with a f Urethra . 

single nucleus A Bladder (trigone), 
generally. [_ 

With two nuclei f peMg of kidney- 
or one nucleus, ' Ureters __ super - 
andnuclei form 



• granulations. 



Much smaller. 



■< 



i 



ficial layer. 

Kidney — rarely 
in an isolated 

state. 
Bladder — near 
the neck. 



PRACTICAL URINALYSIS. 



61 



2.!Epithelialcells 
lamellar, very 
thin, polygo- 
nal. 



-< 



i 



A large nucleus, 
and often two 
nuclei and nu- 
cleiform gran- 
ules. 

Very large la- 
mellae, but with 
very small nu- 
cleus. 



< 



< 



Pelvis of the kid- 
ney and ureters 
— superficial 
layer. 

Vaoina and ex- 
ternal genital 
parts. 

Urethra, near 
meatus. 



3. Cylindrical, columnar, 
spindle-shaped, epithelial 
cells, with tail longer or 
shorter and more or less 
bent. 



< 



Bladder. 
Ureters. 
Pelvis of the kidney. 




Fig. 16. 
A —Glandular epithelium from the kidneys. B — Tesselated-epithelium from the 
pelvis of the kidneys. C— Epithelium with large and distinct nuclei from the 
ureters. D— Columnar epithelium, from the fundus of the bladder. H,.— .Large 
flattened cells, with a very distinct nucleus and nucleolus, from the trigone of the 
bladder. F.— Epithelium of the bladder.— (King.) 

These cells appear large in comparison with blood or 
pus-corpuscles wdien the same power is used to detect 



62 



PRACTICAL URINALYSIS. 



both. The central structure enclosed within the cell- 
substance is called the nucleus. 




Fig. 17. 

a round epithelium from bladder; b, columnar epithelium from ureter and 
urethra ■ c 1 columnar and squamous epithelium from deeper layers of epithelium 
of bladder \ c 2, squamous epithelium from superficial layers of epithelium of 
vagina. — Tyson. 

Detection of Casts. — Casts must be identified by the 
microscope. In order to collect them for examination 
proceed as follows : 

(a.) If the urine contains no deposit 

1. Collect the urine for twenty-four hours. 

2. Let it stand in a tall cylindrical glass from twelve to 
twenty-four hours according to the amount of albumin 
present, the more the longer. 

3. Pour all the urine away except the four or five 
ounces at the bottom. 

4. Let this four or five ounces settle again for two or 

three hours. 



PKACTICAL URINALYSIS. 63 

5. Take a drop of urine from the bottom with a pipette 
(or pour the urine into another vessel and examine one of 
the last drops) put it on a slide furnished with a shallow 
gum-dammar or cement cell and examine with a power of 
from 100 to 250 diameters (low power in order co include 
a considerable quantity of urine). 

6. Haviiio; found tube-casts, study them with a higher 

O 'ml C5 

power namely, 400 to 800 diameters. 

7. If casts be not found on one slide try several, and 
do not decide upon the case until several examinations 
haye been made at intervals of several days. 

(5.) When the urine contains a deposit: 
If the urine contain an abundance of casts thev are 
much more readilv found : 

ml 

1. Let the urine settle a few hours. 

2. Pour off the supernatant urine from the deposit 
which has settled and examine one of the last drops on a 
slide with a shallow cell, as before in a. 

Three or four varieties of casts mav be seen : 

I. Epithelial, (Fig. 18 5 ) consisting of a mass of epi- 
thelial cells from tubules of kidnev ; thev are generally 
wide, seldom narrow. 

II. Granular, (Fig. 18 2 ) epithelial casts which have 
undergone molecular change are called "o-ranular" owino* 
to their dark, nearly black, coarsely granular aspect. 
Granular casts may be studded with minute oil globules, 
(Fig. 18) in w^hich case they are called "fatty or oil casts." 
Granular casts may haye blood-corpuscles on them, in 
which case they are called " blood casts"; hi such a case 
they appear either as (i.) perfect cylinders composed of 
delicate circles placed in apposition or (ii.) more often 
fibrinous cylinders irregularly studded with blood-cor- 
puscles, some perfect, others shrunken and contorted or 



64 



PRACTICAL URINALYSIS, 



(iii.) blood -corpuscles, crushed or compressed into a 
cylindrical mould. In case the material of the granular 
casts be derived from broken-down blood-corpuscles, the 
casts will appear yellowish or yellowish-red. Granular 
casts may be large or small, full of granular matter or 
only partially filled. 




Fig. 18. 
r Massive fibrin cylinder 2-Granular cast. 3— Hyaline casts 4-Waxy 
cas^ 5-EpitheUal casts. 6-Uric acid casts.-(Hofmann-Ultzmann.) 

III. Hyaline, Structureless or Waxy, (Fig. 18 » and *) 
These are clear cylinders with well-defined margins deline- 
ated by a distinct line. They are sometimes rectilinear 
but more often curvilinear, having their extremities cut 
like glass ; their surface is generally polished. Hyaline 



PRACTICAL URINALYSIS. 



65 



casts are formed of homogeneous, transparent material, 
and contain cracks and roughnesses due to blood globules 
and epithelial cells with here and there one or two 
glistening oil drops ; their outlines are often so indistinct 




Fig. io. 

that before they can be detected thev must be artificially 
tinted with iodine or magenta, or the light from the mir- 
ror illuminating the field of view must be modified bv 

L. 

shading with the hand or by manipulating the mirror 

itself, the field of view being just outside the exact focus. 

Hyaline means " transparent like glass,'' hence the 

name of these casts ; when they are of more solid aspect 

they are termed ••waxy'" casts, from the resemblance to 

"molten'" wax. Amyloid casts are hyaline casts which 

have undergone metamorphosis. 

In advanced stages of Bright s disease the hyaline casts 
5f 



gg PRACTICAL URINALYSIS. 

may be completely enclosed in a cortex of epithelial cells 

from renal tubules. 

IV. Mucus Oasts, (Fig. 20). Not to be confounded 
with hyaline casts are those called mucus, which may 
frequently be found in normal urine ; they have badly 
defined margins, are often twisted or varicose, but they are 
pale and smooth. Mucus casts are characterized by their 
great length, which is often enormous, in the course of 
which they divide and subdivide, diminishing in diameter 





1 ^m 




- /,\ -'■..:. :.■'.'•*•.?&-' <,, ' sS * , ^ ^k^^y^^S 













mmy\ 



Fig. 20. 



as the division proceeds. They are often present with pus. 
According to Beale, also in urine of high specific gravity 
(1030 and upward) containing excess of urea and urates. 
As they are of no diagnostic value they must not be mis- 
taken for hyaline casts. 

Acetic acid renders them fibrillary and punctated, but 

attacks hyaline casts very slightly. 

Besides the four varieties of renal casts mentioned, 
there are sometimes present in urine casts of the seminal 



PRACTICAL URINALYSIS. 67 

tubules which may be distinguished, microscopically, from 
the preceding by the presence in them of spermatozoids. 
Fibres of wood, cotton, flax, wool, silk are often mis- 
taken for casts, likewise hair and other foreign bodies ; if 
some of the deposit be placed on a slide and a thin glass 
cover put over it, pressure on the cover with a needle will 
crush a renal cast but merely flatten any foreign body 
likely to be present. Hence it is desirable not to look for 
tube casts on an ordinary slide with a cover lest they be 
crushed ; it is better to use, as previously specified, a slide 
with a cell in it. 

To decide whether an object seen with the microscope 
is a tube cast or not proceed as follows : 

1 . Rule out foreign bodies by the method of procedure 
given above. 

2. Notice whether imbedded in or firmly adherent to 
the object are epithelial cells from uriniferous tubules, 
red blood-corpuscles or leucocytes. If no epithelial cells 
at all, examine several slides before concluding whether 
the objects are casts or not, since in the last stages of 
Bright's disease the uriniferous tubules have, in some 
cases, been stripped of their lining epithelium, hence no 
cells will be seen in or on the casts. 

3. t Observe the extremities of the object under examin- 
ation ; casts usually have round or club-shaped extremities. 

4. Casts are colored by carmine solutions ; vegetable 
elements, fungi, etc., are not so colored. 

Bear in mind the fact that a urinary deposit may, and 
generally does, contain a mixture of two or more varieties 
of casts and cells, hence ground your opinion upon the 
variety which is most and best represented. 

Remember (a) that epithelial casts often contain besides 
epithelial cells and red blood-corpuscles, white blood-cor- 



gg PRACTICAL URINALYSIS. 

puscles, pus-corpuscles, urates, uric acid and especially 

oxalate of lime crystals. 

Remember (b) that in icteric complications all casts 
may be colored by bile or interspersed with urates or 
crystals (cleared by acetic acid). 

Recognition of Spermatozoa.— Spermatozoa found in 
urine have no movement unless a very considerable amount 
of pus be present ; they resist elements of destruction 
very successfully and may be found intact in putrid urine, 
of several months age. Ammonia rapidly destroys their 

°When present in the urine together with the seminal 
fluid a glairy, white deposit is found, but the spermatozoa 
themselves are not visible to the naked eye. 




a 



& 



Fig 2i.— human spermatozoa. 
, ._ 3SO . 2 ._8oo diameters', a. viewed from the side; *, from the front. 

Let the deposit settle as usual, dip in the pipette and 
place a drop on the slide ; if there are many ingredients 
of the deposit interfering with a recognition of the sper- 
matozoa add a little acetic acid if the deposit is phosphate, 
or a little 10 per cent potassa solution if of urates. Use 



PRACTICAL URINALYSIS. 



69 




Fig. 22. 

i. Yeast fungi. — 2. Penicilium glaucum. — 3. Sarcina. — 4. Cyst of the echinococcus 
with detached hooks. — Hofman and Ultzmann. 



a power of 250 diameters first, in case only a few should 
happen to be present, afterward 400 to 600 diameters, to 
show them well. They have an oval or pear-shaped head 
or body and a long, extremely delicate, finely tapering tail. 
They are very refractive and of a peculiar bluish tint and, 
as it were, of a fatty lustre, hence most easily detected 
when viewed just outside of or beyond the exact focus. 
(Fig. 22.) 

Fungi. — Any one inexperienced in the use of the micro- 



70 PRACTICAL URINALYSIS. 

scope may be misled by the appearance of certain 
organisms frequently found in urine and known as fungi. 
Four varieties are of interest (Fig. 23): (L) Sarcinse ; 
(ii.) bacteria; (iii.) penicilium glaucum ; (iv.) torula 
cerevisise. The only fungi found in freshly-voided urine 
are those called sarcince; these are (Fig. 22 3 ) square 
bodies subdivided into secondary squares which number 
2, 4, 8, etc., resembling those found in the vomited mat- 
ter 'of persons suffering from stenosis of the pylorus 

although smaller. 

After urine has been voided some little time other 
organisms maybe found in it. Penicilium glaucum 
(Fig. 22 2) is the common blue mould found in vinegar 
and all albuminous fluids ; when urine contains albumin 
a plentiful amount of this fungus may be found a few 
hours after it has been passed. Its sporules may be mis- 
taken for blood-corpuscles, but if set aside for a few days 
they bud and the thallus is produced from which eventu- 
ally spring the ascending stems of the aerial fructification. 
These fungi flourish in acid urine, but perish in alkaline. 
It will be remembered that fungi are not colored by 
carmine solutions, while casts, epithelia, etc., are. Torula 
cerevisia? (Fig. 22 1) is the yeast or sugar fungus, but may 
be found in urine which contains no sugar ; nevertheless, 
in diabetic urine it begins to form in a few hours, and is 
often developed in twenty to thirty-six hours after the 
urine has been voided, beginning as sporules and develop- 
ing into thallus and aerial fructifications. It is difficult 
to & distinguish torula cerevisise from penicilium glaucum 
until the°aerial fructification has been reached, in which 
the torula has a globular head while the penicilium 
presents a tuft of branches. 

When urine for any reason is decomposed, very delicate 



PRACTICAL URINALYSIS. 71 

bodies called bacteria may be seen, with a power of 200 
diameters, exhibiting active motion, rotary or vibratory. 
A power of 500 diameters is required to show them well. 




FlG. 23. — BACTERIA AND VIBRIONES. 

From urine three days old; 403 diameters. — (Beale.) 

Vibriones or vibrios (Fig. 23,) are filiform bodies, more 
or less distinctly jointed from imperfect division, and 
having an undulating movement like that of a serpent. 

CLINICAL SUMMARY. 

(Organized Deposits.) 

Blood in the urine is significant of haemorrhage some- 
where in the urinary tract ; it is found (i.) in the various 
forms of Bright' s disease, (ii.) in bladder or urethral affec- 
tions, (hi.) after the administration of certain drugs. It 
must be remembered that the urine of menstruating 
women or those suffering from uterine or vaginal 
haemorrhage may contain blood. Urine containing blood 
will answer the tests for albumin. To tell whether 
albumin found in urine when blood is present be kidney 
albumin or simply that due to the presence of blood look 
for evidences of kidnev disease ; examine the urine for 
tube-casts, etc. 

Blood coloring matter is found in the urine in certain 
diseases which accompany dyscrasia and blood degenera- 
tion, as hi scurvy, putrid typhus, etc. Temporary presence 
of blood coloring matter in the urine is of no serious 



72 PRACTICAL URINALYSIS. 

import ; when permanently found the prognosis is doubtful. 
Urine containing blood coloring matter has a color varying 
from red-brown to inky-black, and on boiling yields a 
brown-red coagulum. 

Pus in the urine is significant of suppuration somewhere 
in or near the urinary tract ; it may and most commonly 
does proceed from some local condition of the bladder. 
In women pus in the urine may be due to vaginal causes 
in which case an abundance of epithelium of the pavement 
variety may be seen with the microscope. An abscess 
bursting into the urinary passages will make itself known 
by the sudden presence of a large amount of pus in the 
urine. Urine containing pus will be found to contain 
albumin due to the pus; to differentiate from kidney 
albumin look for evidences of kidney disease as in case 

of Blood. 

Mucus in abnormal quantity is indicative of irritation 
of the mucous membrane of the urinary passages. This 
irritation may develop into inflammation when it will 
occur mixed with pus. The amount of mucus is increased 
in fevers and acute diseases ; after gonorrhoea long mucous 
"plugs" maybe found in the urine. Irritation of the 
genital mucous membrane in women may cause consider- 
able mucus to be found in the urine. 

Epithelium in the urine may be found in increased 
quantity in the various diseases of the uro-poetic system. 
In female children of a strumous diathesis it is plentiful in 
the urine. An amorphous-looking, light, cloudy deposit' 
abundant in quantity is frequently found in the urine of 
females, consisting of epithelial cells from the vagina; 
this deposit will be greatly increased in leucorrhoea. 

Tube-casts are found in the urine in all cases of renal 
congestion and in acute or chronic Bright' s disease. If 



PRACTICAL URINALYSIS. 73 

tube-casts are found in the urine for several weeks, it is 
well to examine the urine carefully for other constituents. 

I. A plentiful amount of albumin with numerous casts, 
and renal epithelia or fatty cells strongly indicate Bright' s 
disease ; if the casts are granular or hyaline a grave disease 
of the substance of the kidney likely to assume a chronic 
course is indicated; if hyaline casts are present accompa- 
nied by the oily variety of granular casts the prognosis is 
unfavorable. 

II. Pus and casts together indicate severe inflammatory 
process (pyorrhoea) either in the parenchyma of the 
kidney or in the calices and pelves. 

III. Blood and casts indicate probably, a disease of the 
vessels of the kidney, such as fatty or amyloid degeneration 
of the renal arteries. 

IV. If the casts contain dailv a considerable amount of 
fat we may surmise fatty degeneration of the kidneys. 

V. Casts of very small diameter may indicate narrowing 
of the renal tubules ; casts of very large diameter may 
indicate dilatation of the renal tubules; casts of very 
unequal diameter, with bulgings and contractions, may 
indicate a varicose or distended condition of the renal 
tubules. 

Spermatozoa may frequently be found in the urine of 
males in a state of health. Constant presence of them 
together with other symptoms may indicate that mastur- 
bation is practiced. They are found in the urine voided 
after coition or nocturnal emissions, during typhus, and 
in the so-called " spermatorrhoea." 

Fungi are usually found in urine containing albumin 
or sugar, or that which has begun to decompose. Sarcinae 
may be found in freshly voided urine in cases of vesical 
catarrh, dysuria, renal pains, dyspepsia, hypochondria. 



74 PRACTICAL URINALYSIS. 

Bacteria indicate that putrefactive changes in the urine 
have set in. Vibriones or vibrios may be found in the 
pale urine of cachectic and debilitated persons and those 
extremely prostrated by phthisis, mesenteric and syphilitic 

diseases. 



NORMAL CONSTITUENTS. 

After having ascertained the physical characteristics of 
urine, and examined it for abnormal constituents it is 
well after identifying the contents. of any sediment to 
filter the urine and test it for its normal constituents. 

Detection of Urea. — No simple qualitative test for urea 
is known, but all operations tend to show the amount of 
urea present in the urine. The following method has 
been recommended as sufficiently accurate for practical 
purposes in determining the amount of urea present in a 
given specimen of urine : 

Upon a glass, slide place a drop or two of the urine at 
ordinary temperature and add to it an equal quantity of 
concentrated nitric acid ; if crystals (urea nitrate) form 
at once or within five minutes, there is an excess of urea. 
If the crystals form in from five to ten minutes the amount 
of urea is normal If the crystals do not form in ten 
minutes there is a deficiency of urea. 

In cases where it is desirable to know the amount of 
urea excreted in a day collect the urine for twenty-four 
hours and estimate the urea by the method of Fowler. 

Fowler's Method for the Estimation of Urea. — Obtain 
some standard solution of chlorinated soda (Squibb) and 

proceed as follows : 

(i.) Take the specific gravity of the twenty-four hours 
urine and of the chlorinated soda solution, separately. 



PRACTICAL URINALYSIS. 75 

Add the specific gravity of the urine to that of the soda 
solution after multiplying the latter by 7 ; for example 
suppose the specific gravity of the urine to be 1015 and 
that of the soda solution 1048 ; 1048 x 7 = 7336 ; add 
7336 to 1015 and we have 8351. Next divide the same 
by 8 — in this case 8351 -4- 8 = 1044, nearly. Then mix 
15 parts of the urine, say 15 cubic centimetres, with 105 
parts of the soda solution, say 105 cubic centimetres, 
shake well and let stand for at least two hours, after 
which take the specific gravity and subtract it from the 
result of the division by 8. The difference multiplied by 
3.55 will give the number of grains of urea to each fluid 
ounce of urine under examination (the difference multi- 
plied by 7.791 will give the number of milligrams of urea 
to the cubic centimetres of urine). Further multiplication 
by the total number of ounces of urine passed during the 
twenty-four hours will give the total amount of urea in 
grams. Thus, suppose in the case mentioned above, after 
mixing, the specific gravity was found to be 1041 ; sub- 
tract this 1041 from 1044 (the result of the division by 8) 
and the difference is 3. Multiply 3 by 3.55 and we find 
10.65 grains of urea to the ounce. Suppose 40 ounces of 
urine were passed during the twenty-four hours — then 
10.65 multiplied by 40 = 426 grains of urea voided in 
twenty-four hours. 

It is evident that with this method we must be able to 
fix the point at which the urinometer floats in the several 
liquids with nicety. When these liquids are perfectly 
transparent there is no difficulty, the proper way being to 
read from the under surface of the fluid bringing the eye 
on a level with that surface. When the urine from any 
cause is opaque either filter it carefully or resort to the 
following simple device recommended by Fowler : Take a 



76 PRACTICAL URINALYSIS. 

piece of soft pine and shape it into a circular disk some- 
what smaller than the calibre of the smallest cylinder to 
be used. Make it exceedingly thin and uniform and 
perforate it in the centre with a round hole which will 
freely accommodate the stem of the urinometer. Having 
put the stem of the instrument thiough this opening and 
immersed it in the fluid, the bit of wood will float on the 
surface, and the specific gravity can be readily taken by 
noting the point at which the float comes in contact with 
the stem. The weight of the wood will cause a slight 
increase in the specific gravity, but when used in every 
case the error will be the same and correct itself. 

Detection and Estimation of Sodium chloride. — Filter the 
urine, fill a clean test-tube half full of it, add two or three 
drops of nitric acid, and a liberal amount of silver nitrate 
solution ; a heavy white precipitate of a cheesy appearance 
(silver chloride) soluble in ammonia indicates presence of 
salt in the urine. In acute diseases the more abundant this 
precipitate as a rule the more favorable the indication ; 
care must be taken to add a few drops of nitric acid 
always before adding the silver nitrate as this prevents the 
precipitation of silver phosphate. If the urine to be tested 
contain albumin heat, add a few drops nitric acid, filter 
and to the filtered urine add silver nitrate. To estimate 
roughly the amount of salt in urine from day to day collect 
the urine for twenty-four hours and filling a test-tube 
exactly half full add two or three drops of nitric acid, then, 
drop by drop, a solution of silver nitrate (strength 1 in 10) 
stirring after each drop with a glass rod until no further 
precipitate forms on adding the nitrate. Set the tube 
aside and on the next day repeat the operation just 
described, remembering to use a test-tube of the same size 
as on the preceding day. After the precipitate has settled 



PRACTICAL URINALYSIS. 77 

to the bottom of the tube it may be compared in bulk 
with that of the preceding day. 

Detection of Sulphates. — Pill a clean test-tube half full 
of urine, add a few drops of hydrochloric acid then some 
solution of barium chloride ; a white precipitate which is 
not dissolved on further addition of nitric acid indicates 
presence of sulphates. 

Detection of Phosphates. — If the urine be clear, contain- 
ing no sediment, and of acid reaction, fill a test-tube half 
full of it, add ammonia and heat. A flocculent precipitate 
appearing indicates presence of earthy phosphates ; filter 
the urine ana to the filtrate add solutions of ammonium 
carbonate and magnesium sulphate. White flocculent 
precipitate indicates presence of alkaline phosphates. 
(When the earthy phosphates form a sediment or deposit 
proceed as under Deposits ; the methods just mentioned 
are merely given to enable the physician to tell whether a 
given specimen of urine contains phosphates in fair 
amount or not). 

Estimation of Phosphates. — In most cases a study of the 
variations in amount of the earthy phosphates will be a 
sufficient clinical guide. 

Obtain a specimen of normal urine — preferably a sample 
of the mixed urine of twenty-four hours — and after filter- 
ing it place 10 cubic centimetres into a tube or glass jar 
and add to it 5 cubic centimetres of ammonia. Agitate 
thoroughly as before and allow the mixture to rest. The 
next day observe the height of the precipitate in the tube ; 
if the latter be graduated, say into fifths of a cubic centi- 
metre, the accuracy of the operation will be greatly 
increased. Having thus observed how heavy a precipitate 
forms in the normal urine apply the same method of 
procedure to a specimen of supposed abnormal, and a great 



78 PRACTICAL URINALYSIS. 

excess of earthy phosphates in the latter will be indicated 
by a great comparative height of the precipitate in the 
tube. To obtain satisfactory results a specimen of the 
urine of twenty-four hours should, in each case, be used ; 
for instance, suppose the normal urine used were that 
passed after drinking three or four glasses of water, and 
the abnormal that passed on rising in the morning— to 
draw any conclusions from the comparison of two such 
widely differing specimens would be absurd. For further 
consideration of phosphates see Deposits. 

Detection of "Urates.— This may be accomplished by 
adding to ten parts of urine one part of hydrochloric acid. 
Allow the mixture to stand thirty hours in a cool place 
when crystals of uric acid will form, recognized by the 
naked eye or by the microscope. See Uric acid Deposits. 
Detection of Coloring Matter.— (1) Fill a clean test- 
tube half full of urine and allow twenty or thirty drops of 
nitric acid to trickle down the sides of the tube into the 
urine ; when the acid and urine meet a zone of light 
pinkish-red color will be observed, indicating presence of 
uro-hematin. The darker the zone the more the uro- 
hematin. The color is best observed by holding against 
a white object. (2.) Fill a clean test-tube half full of 
urine and allow twenty or thirty drops of pure hydro- 
chloric acid to trickle down its sides. Where the urine 
and acid meet a zone of violet color gradually developing 
itself indicates presence of indican ; the more the indican 
the bluer the color of the zone. 

Detection of Mucus.— Where mucus is not visible on 

careful examination addition of acetic acid to the urine 

will coagulate the mucin and render it plainer to the eye. 

Detection of Creatinin and of Hippuric acid.— Creatinin 

is only detected by a long chemical process not suitable to 



PRACTICAL URINALYSIS. 79 

describe here. The same may be said of hippuric acid. 
See Bare Deposits. 

CLINICAL SUMMARY. 

(Normal Constituents.) 

Urea is increased in acute febrile states and in diabetes ; 
it is decreased in Bright' s disease and in long-continued 
organic diseases in general. 

Sodium chloride is decreased (sometimes absent) in acute 
diseases, especially inflammations attended by exudations, 
as pneumonia. 

The Sulphates are of little clinical importance. 

The Phosphates may be increased in inflammatory dis- 
eases of the nervous system and in cases of nerve lesions 
in general ; also in certain cases of diabetes. They may 
be decreased in Bright's disease. — Brattler. 

The Urates are similar in significance, when not found 
as a deposit, to urea. 

Urohematin is increased in acute febrile disorders and 
often in diabetes ; it is diminished usually in anaemia and 
chlorosis. 

Indican may be increased in the urine of persons far 
advanced in phthisis, or suffering from cancer. 



EXAMINATION OF URINARY CALCULI. 

To make a thorough and systematic examination of 
urinary calculi one has need of a jeweler's saw and agate 
mortar, platinum foil, several watch glasses, an alcohol 
lamp and a good knife with small, sharp blades, together 
with various reagents. See Part II. 

-An approximate idea of the most important calculi may 
be gained from the following : 



80 PRACTICAL URINALYSIS. 

Uric acid calculi are relatively very common and may 
reach a very considerable size. They are usually yellowish, 
reddish, or red-brown, rarely white, and generally have a 
smooth surface and are tolerably hard. 

Phosphatic calculi may be of considerable size ; they 
usually have a whitish color and are soft, porous and 
chalky or denser and harder according to the particular 
phosphate which predominates in them. 

Oxalate of Lime calculi are tolerably frequent, especially 
in children. They are either small, pale, and smooth— 
hemp seed calcull-or are larger, of rough exterior, tu- 
berculated, warty and colored on the surface, usually dark 
brownish or even blackish— mulberry calculi 

Carbonate of Lime calculi are rare but are easily detected 
by the property of dissolving with effervescence in hydro- 
chloric acid. 



PART II. 




CLINICAL SIGNIFICANCE OF 

UBINE. 



NORMAL URINE. 

Average Composition of Normal Urine in 1,000 Parts. — 

Water, 949.25 

Solids, 50.75 

Total, 1000.00 

Organic. 

Water, 949.35 

Urea, 26.00 

Creatin, traces 

Creatinin, 1.50 

Urates of Sodium and Potassium, - 1.75 

Free Uric acid, traces 

Mucus and coloring matter, - - - 0.25 

Inorganic. 

Acid Phosphate of Sodium, - - - - ) fi 9 - 

Phosphates of Calcium and Magnesium, j " D 

Chlorides of Sodium and Potassium, - 9.25 

Sulphates of Sodium and Potassium, - 5.75 

Total, 1000.00 

Normal Urine. — Normal urine is a clear liquid of a 
color varying from light straw to reddish yellow, possessed 
5f 



82 CLINICAL SIGNIFICANCE OF URINE. 

of an odor peculiar to itself and consisting chiefly of water 
holding various substances for the most part in solution, 
such as urea, common salt, phosphates, etc. 

Quantity of Normal Urine in Twenty -four Hours. — In 
general terms the healthy adult passes from forty to sixty 
fluid ounces of urine during the twenty-four hours. 

Observations of the Author on the Quantity of Urine 
Passed Daily. — Having had opportunity to measure the 
daily quantity of urine passed by an adult man in good 
health, I give the result of sixty-eight successive daily 
measurements as follows : 

1st day, - 1008 cubic centimetres. 

2d " ... . 1100 " « 

3d " - - - 705 " " 

4th " .... 1625 " « 

5th « - - - 1135 " « 

6th " - - - - 1104 " « 

7th " .... 897 « " 

8th " - 1510 " " 

9th " .... 1120 « " 

10th " ... - 1592 



11th " ... - 952 " 

12th " .... 898 « 



a 









13th " .... 1188 

14th " .... 901 « « 

15th « - - - ' - 1186 '« 

16th » .... 1183 

17th « .... 1901 

18th " .... 1476 

19th " .... 1610 

20th » .... 1553 

21st « - - - - 1326 

22d « .... 911 



a 

a a 

it ft 






CLINICAL SIGNIFICANCE OP URINE. 83 

23d day, - - - - 1580 cubic centimetres. 

24th « 

25th " 

26th " 

27th « 

28th « 

29th « 

30th « 

31st « 

32d « 

33d « 

34th « 

35th « 
36th " 

37th « 

38th « 

39th " 

40th " 

41st « 

42d " 

43d « - - 

44th " 

45th « 

46th " - 

47th « 

48th " 

49th " 

50th " 

51st « 

52d « 

53d « 

54th " 

55th « 



- 


965 


66 


it 


- 


1885 


66 


66 


- 


1283 


66 


a 


- 


975 


a 


66 


- 


1106 


a 


66 


nearly 


1250 


a 


a 


a 


1300 


(( 


a 


a 


1100 


a 


66 


a 


1200 


a 


a 


a 


1500 


a 


a 


a 


1500 


a 


a 


a 


1300 


a 


a 


a 


1250 


a 


a 


a 


1600 


a 


66 


a 


750 


a 


66 


a 


1700 


a 


66 


a 


900 


a 


66 


(( 


1600 


a 


66 


a 


900 


a 


66 


a 


1300 


a 


66 


a 


2200 


a 


66 


a 


1600 


a 


66 


a 


1700 


66 


66 


a 


1200 


a 


66 


a 


1500 


a 


66 


a 


1000 


a 


66 


a 


1600 


a 


66 


a 


1300 


a 


66 


a 


1200 


a 


66 


a 


1200 


a 


66 


a 


1000 


a 


66 


a 


1500 


66 


66 



84 CLINICAL SIGNIFICANCE OF URINE. 

56th aay - - nearl y 1200 cubic centimetres. 

57th « ' - - " ^ 00 " 

58th " 

59 th « - - " 

60th " - - " 

61st " " 

62d " - - 

63d " morning and night only 600 

64th « ----- 1200 

65th * - - " - 1*>J 

66th « # - ■ - 120 ° 

. - - 1300 

. - - 1400 



1325 
1025 
900 
1200 
1300 



« « 

a « 






67th " - ' " " 

68th " - • - 

During the first twenty-eight days the measurements 
were made with close accuracy ; during the last forty days 
the quantity was measured and the results given in round 

numbers. 

Daily average for first 28 days, 1249.46 c. c. 

« « « last 39 days, 1300 « " (nearly). 
Greatest quantity voided on any day 2200 c. c. 
Least « - " " " 705 

On the sixty-third day owing to unavoidable circum- 
stances, only the urine passed in the morning and at night 
* was collected, amounting to 600 cubic centimetres ; the 

quantity for that day is therefore omitted in making np 

the averages. 

During the sixty-eight days, when the daily amount was 
being collected and measured, a routine life was led, late 
hours avoided, and no alcoholic liquors of any kind taken, 
and every care observed that one day should be as nearly 
alike another as possible. The diet was as nutritious and 
hearty as compatible with a sedentary life, indigestible 
food being carefully shunned. The only fluids taken 



CLINICAL SIGNIFICANCE OF URINE. 85 

were cold water (without ice) between meals, and at meals 
very weak tea ; no coffee was drank during the entire 
period and the tea was made as weak as was possibly 
palatable. A small amount of very mild tobacco was 
smoked after lunch and after dinner, the latter being at 
six o'clock. It would appear, therefore, that a healthy, 
well-nourished, male adult, leading a quiet life and not 
drinking much, passes on an average from 1250 to 1300 
cubic centimetres of urine daily, or about forty-two fluid 
ounces. Persons of active temperaments and strong con- 
stitutions may pass, normally, considerably more than 
forty-two fluid ounces ; in fact, various conditions affect 
the daily quantity of urine in the healthy individual as 
follows : 

Circumstances not due to disease or drugs increasing the 
amount of urine. 

f. Activity of the kidneys : greater during bodily and 

mental activity and less during rest and sleep. 

II. Copious drinking of fluids, especially when little 
perspiration. 

III. Cold, damp weather (little perspiration). 

IV. Animal diet : nitrogenous food in general. 

V. Non-retention in bladder for any length of time. 

VI. Age and sex : children relatively more than adults ; 
males than females. 

Circumstances not due to disease or drugs decreasing the 
amount of urine. 

I. Inactivity of kidneys : during rest and sleep or 
abstinence from mental or physical exertions. 

II. Abstinence from drinking. 

III. Activity of cutaneous and pulmonary exhalations, 
(after exercising accompanied by profuse perspiration, 
urine scanty). 



86 CLINICAL SIGNIFICANCE OF URINE. 

IV. Warm, dry weather : (much perspiration). 

V. Non-nitrogenous diet. 

VI. Ketention in the bladder for some time: (reab- 
sorbed into the circulation). 

VII. Age and sex. (See above). 

Quantity of Urine Passed at Different times in the day. — 
The urine passed on rising in the morning is called 
urina sanguinis, that after a meal urina cihi or chyli, that 
after drinking urina potus. 

When the daily quantity for sixty-eight days was col- 
lected account was kept of the urine voided at different 
times in the day for the first twenty-eight days as follows : 

1st day, urina sanguinis, - - 178 cubic centimetres. 

12 noon, - - - - 55 " 

1.30 p. m., - - - 100 

6.30 " - - - - 400 " 

10.30 ^ .... 275 « 

Number of urinations, 5. 

2d day, sanguinis, - - - - 125 cubic centimetres. 
3.30 p. m., - - - - 475 
10.30 " - - - - 400 " 

Number of urinations, 3. 

3d day, sanguinis, - - - - 150 cubic centimetres. 
12 noon, - - - - 175 
3.30 p. M., - - - - 110 
6.00 « - - - - 100 " 

10.30 " - - - - 170 " 

Number of urinations, 5. 

4th day, sanguinis, - - - - 275 cubic centimetres. 
1.00 p. m., --- 200 
3.30 " - - - 460 . « 

6.00 " - - - 175 " 

11.00 " - - - 515 " 

Number of urinations, 5. 



CLINICAL SIGNIFICANCE OF URINE. 87 

5th day, sanguinis, - - - - 220 cubic centimetres. 

1.00 p. m., - - - 160 « 

3.30 « - - - 155 

5.30 " - - - 200 « 

11.00 " - - - 400 " 

Number of urinations, 5. 

6th day, sanguinis, - - - - 245 cubic centimetres. 

1.00 p. m., - - - 185 

3.30 " - - - 337 

10.00 " ... 337 

Number of urinations, 4. 

7th day, sanguinis, - - - - 337 cubic centimetres. 
2.30 p. m., - - - 160 « 

10.30 " - . . 400 

Number of urinations, 3. 

8th day, sanguinis, - - - - 305 cubic centimetres. 
3.00 p. m., - - - 135 
7.00 " - - - 400 « 

9.30 " - - - 700 « 

Number of urinations, 4. 

9th day, sanguinis, - - - - 280 cubic centimetres. 

1.00 p. m., - - - 125 " 

3.30 " ... 275 

6.30 " ... 160 « 

11.00 « ... 280 

Number of urinations, 5. 

10th day, sanguinis, ... - 337 cubic centimetres. 

12 noon, .... 175 " 

3.30 p. m., - - - 345 

6.30 " - - - 350 

11.00 « ... 385 « 

Number of urinations, 5. 

11th day, sanguinis, - - - - 130 cubic centimetres. 

12.30 p. m., - - - 95 

3.30 " - - - 366 " 

4.30 « ... 83 « 



(4 



U 






88 CLINICAL SIGNIFICANCE OF URINE. 

10.00 p. M., - - - 278 cubic centimeters. 
Number of urinations, 5. 

12th day, sanguinis, - - - - 260 cubic centimetres. 
2.00 p. m., - - - 140 " 

7.30 « - - - 278 

10.00 " --- 220 

Number of urinations, 4. 
13th day, sanguinis, - - - - 278 cubic centimetres. 
11.00 A. m., - - - 80 
2.00 p. M., - - - 270 
4.30 " - - - 290 

10.00 « - - - 270 

Number of urinations, 5. 
14th day, sanguinis, - - - - 330 cubic centimetres. 
12 noon, - - - - 140 
10.30 p. M., - - - 431 
Number of urinations, 3. 
15th day, sanguinis, - - - - 278 cubic centimetres. 
3.30 p. M., - - - 278 
6.30 " - - - 225 

9.00 " - - - 475 " 

Number of urinations, 4. 

16th day, sanguinis, - - - - 278 cubic centimetres. 

12 noon, - - - - 100 

6.00 P. M-, - - - 580 " 

11.30 " - - - 225 " 

Number of urinations, 4. 

17th day, sanguinis, - - - - 278 cubm centimetres. 

12 noon, - - - - 225 

3.30 p. M., - - - 813 " 

6.30 " - - - 425 " 

10.15 « - - - 160 
Number of urinations, 5. 

18th day, sanguinis, - - - - 333 cubic centimetres. 

12 noon, - . - - 195 " 



CLINICAL SIGNIFICANCE OF URINE. 89 

3.30 p. m., - - - 278 cubic centimetres. 
6.30 " --. 520 " 

10.00 " - - - 150 

Number of urinations, 5. 

19th day, sanguinis, - - - - 361 cubic centimetres. 

12 noon, - - - - 160 " 

3.30 p. m., --- 603 

6.00 " - - - 323 « 

10.30 « - - - 163 « 

Number of urinations, 5. 

20th day, sanguinis, - - - - 340 cubic centimetres. 

12 noon, - - - - 180 " 

3.30 p. M., - - - 338 

6.00 " --- 417 « 

11.00 " --- 278 

Number of urinations, 5. 

21st day, sanguinis, - - - - 378 cubic centimetres. 

12 noon, - - - - 278 " 

6.30 p. m., - - - 325 " 

11.00 " - - - - 345 " 

Number of urinations, 4. 

22d day, sanguinis, - - - - 278 cubic centimetres. 

4.00 p. m., - - - - 310 

6.00 " - - - - 90 " 

11.00 " - - - - 233 " 

Number of urinations, 4. 

23d day, sanguinis, - - - - 255 cubic centimetres. 

12 noon, - - - - 170 « 

3.30 p. M., - - - - 650 " 

6.30 "■---- 320 " 

10.00 " - - - - 185 " 

Number of urinations, 5. 

24th day, sanguinis, - - - - 300 cubic centimetres. 
12 noon, - - - - 175 « 

6.30 p. m., - - - - 300 
10.30 " - - - - 190 « 

Number of urinations, 4. 



90 CLINICAL SIGNIFICANCE OF URINE. 

25th day, sanguinis, - - - - 390 cubic centimetres. 
12 noon, - - - - 200 " 

3.30 p. M., - - - 745 " 

0.15 " - - - 350 

10.30 " - - - 200 " 

Number of urinations, 5. 

26th day, sanguinis, - - - - 300 cubic centimetres. 

12 noon, - - - - 175 « 

3.30 p. m., - - - 400 

6.30 « - - - 175 " 

10.30 " - - - 133 

Number of urinations, 5. 

27th day, sanguinis, - - - - 300 cubic centimetres. 
6.30 p. m., - - - 500 
10.00 " - - - 175 « 

Number of urinations, 3. 

28th 'day, sanguinis, - - - - 400 cubic centimetres. 

12 noon, - - - - 100 

4.00 p. m., - - - 200 

11.00 " - - - 400 

Number of urinations, 4. 

SUMMARY. 

Average number of urinations, daily, - - - - 4 to 5. 
Average quantity voided at each urination, - 282.1 c. c. 
Greatest quantity voided at any one urination, 813.0 " 
Least quantity voided at any one urination, - 55.0 " 
Average quantity of urina sanguinis, - - - 282.7 " 
Average quantity passed before retiring, - - 299.0 " 

The urine passed before retiring was in in each case, 
as a rule, urina cibi, the principal meal of the day occur- 
ring at 6 p. m. 

The greatest quantity of urine voided at any one urin- 
ation, 813 cubic centimetres, at 3.30 p. m., on the 17th 
day, was combined urina cibi (after lunch at 12.45) and 



CLINICAL SIGNIFICANCE OF UEIXE. 91 

urina potus — three glasses of water having been drunk 
between the hours of 2 and 3 p. m. 

Specific Gravity. — The specific gravity of normal urine 
is said to lie on an average between 1015 and 1025. 

Cincumstances not due to disease or drugs increasing the 
relative amount of solids in the urine, i. e., increasing 
the specific gravity; 

I. Timeofdav: urina sanguinis. 

II. Hearty meals, after : urina chyli. 

III. Causes decreasing the quantity of fluid. 

Circumstances not due to disease or drugs decreasing the 
specific gravity. 

I. Copious draughts of fluids (urina potus). 

II. Causes increasing the quantity of flui:l. 

The specific gravity of urina sanguinis should be from 
1015 to 1025; of urina cibi, 1020 to 1030; that of 
urina potus, 1015 to 1002. 

Solid Constituents. — The urine of an healthy adult con- 
tains dissolved in it from sixty to seventy grammes (925 
to 1075 grains) of solid matters, urea, salts, etc., during 
the twentv-f our hours. 

The method of calculating the amount of solid matters 

contained in the urine of tweutv-four hours is : 

i. 

I. Collect the urine for twentv-four hours. 

%J 

II. Measure it in cubic centimetres bv means of a flask 
graduated in cubic centimetres. 

III. Divide the amount of cubic centimetres found, by 
1000 and set the result aside for the moment. 

IV. Take the specific gravity of the urine. 

V. Multiply the last two figures by 2. — Trapp's Coef- 
ficient. 

VI. Multiply the result by the figure found in (III.) 



92 CLINICAL SIGNIFICANCE OF URINE. 

and the product will be the amount of solids (in grammes) 
in the urine of twenty-four hours. 

VII. To find the number of grains multiply this 

product by 15.4 

EXAMPLE I. 

Amount of urine 3000 cubic centimetres in twenty- 

four hours. 

3000 -^ 1000 = 3. (III.) 

Specific gravity of urine, 1008. 08 X 2 = 16. 16 X 
3 = 48. This urine therefore contains 48 grammes of 
solid matters ;. 48 X 15.4 = 739.2 grains. 

EXAMPLE II. 

Amount of urine in twenty-four hours, 760 cubic 

centimetres. 

760 -h 1000 = .76. (III.) 

Specific gravity of urine 1030. 30x2 = 60. 60 x -76 
= 45.6. This urine contains then 45.6 grammes solid 
matters or (45.6 X 15.4) 702.2 grains. 

Consistence.— Normal urine is a thin, easily dropping 
fluid, foaming if shaken ; this foam vanishes soon on 

standing. . 

Transparence and Fluorescence.— Normal urine is 

always clear and transparent, showing, after standing at 
rest for some time, a very slight turbidity or light, grayish- 
white cloud which gradually settles to the bottom of the 
vessel. This cloud, called nubecula, is derived from the 
bladder and is composed mainly of mucus and epithelial 
cells ; it is generally more apparent in the urine of women 
than that of men, but should never be sufficiently visible 
to attract attention. Normal urine shows at times a 
peculiar white fluorescence. 

Color.— The color of normal urine varies from pale 
straw, or almost colorless after copious draughts of water, 



CLINICAL SIGNIFICANCE OF URINE. 93 

through yellow to red, after hearty meals or free perspi- 
ration; the standard "normal" color as in whiter, is 
wine yellow or amber, called by some "sherry color". 

Odor.— The odor of fresh, normal urine is slightly 
aromatic, and is called "sui generis " — peculiar to itself. 

The odor is stronger in proportion to the amount of 
solids contained in the urine. The urine passed after a 
hearty meal smells stronger than that after copious 
draughts of water. The urine of infants is generally 
inodorous but on standing acquires the agreeable savor of 

veal broth. 

Urine, on standing exposed to the air for some time, 
loses its sui generis odor and takes on, first, a smell some- 
what like that of sour milk and, subsequently, a fetid 
ammoniacal odor. 

Reaction. — Normal urine of twenty-four hours turns 
blue litmus paper dipped into it slightly red ; after a meal 
it may turn neither blue litmus paper red, nor red litmus 
paper blue ; after a meal or after a cold bath it may turn 
red paper blue. In other words, normal urine is slightly 
acid in reaction : it mav be neutral or alkaline after meals, 
or alkaline after a cold bath. Vegetable diet tends to 
make urine neutral. 



ABNORMAL URINE. 

(Physical Characteristics.) 

The quantity, specific gravity, solids, consistence, color, 
transparence, odor, and reaction of normal urine being 
known it is now in order to study the departures from 
normal standards shown in the physical characteristics of 
abnormal urine. 

Increased Quantity of the Twenty-four Hours Urine. — 



94 CLINICAL SIGNIFICANCE OF URINE. 

A large increase in the total amount of urine for twenty- 
four hours is indicative of diabetes, either mellitus or 
insipidus, especially if the daily increase of quantity above 
normal is persistent, and on calculation we find the 
amount of solids likewise increased. 

In diabetes mellitus the daily amount of urine voided 
may be enormous. 

In case the total amount of urine for twenty-four hours 
is increased (above normal) while the solid matters are 
below normal in amount, increase of the water in the urine 
is indicated, which is called hydruria, and is neither dia- 
betes mellitus nor diabetes insipidus. Cases of this sort 
have been noticed in rheumatism, the daily amount 
averaging 3000 cubic centimetres (about three quarts) 
while the average amount of solid constituents was only 
42 grammes (64? grains). "In such cases no emaciation 
results, but, on the contrary, diseased products are often 
removed, as in many cases of hydremia and dropsy". 

Lastly, when the amount of urine is in excess of normal 
and the quantity of solid matters passed remains within 
normal limits we ought to suspect a large amount of fluids 
to have been drunk. 

An increase above normal limits in the total amount of 
urine for twenty-four hours is called polyuria ; polyuria 
may be divided into two classes : increase in amount of 
urine, with increase in solids, called diabetes (two forms 
"mellitus" and "insipidus") and increase in amount of 
urine, with decrease in solids, called hydruria. 

The word polyuria is derived from two Greek words 
signifying "much urine"; the word hydruria, "watery 
urine"; or " flow of much urine " and "flow of watery 
urine" respectively. 

It will be borne in mind that an increased amount of 



CLINICAL SIGNIFICANCE OF URINE. 95 

urine due to excessive drinking is called "urina potus," is 
not pathological since the amount of solids does not ex- 
ceed normal limits in either direction, and does not come 
under the head of polyuria. 

Diabetes, the first form of polyuria, in which the amount 
of the solids is increased, may be of two forms : diabetes 
mellitus and diabetes insipidus. 

Diabetes mellitus (mellitus from met "honey") is 
saccharine diabetes, i. e., diabetes where sugar is present in 
the urine ; diabetes insipidus (insipidus from in and sapor, 
"tasteless") is diabetes where sugar is absent but an ab- 
normally large amount of other solids present in the urine. 

The word diabetes then means "increased flow of urine 
with increased excretion of solid matters," whether sugar 
and normal constituents (in which case the qualifying term 
"mellitus" is added) or normal constituents without sugar 
(in which case the term "insipidus" is used). 

Diabetes of any kind is accompanied by weakness and 
emaciation; hydruria is not accompanied by either of 
these. 

Urine in Bright's Disease. — In certain forms of Bright's 
disease, namely, in interstitial nephritis and in amyloid 
degeneration of the kidney the amount of urine is largely 
increased — even to three or four times the normal 
quantity ; just before death, however, the quantity falls 
below normal. 

Temporary Increase in Amount of Urine. — Temporary 
increase of urine is noted after hysterical paroxysms and 
other convulsive attacks in both males and females. 

Increased Tension. — Anv increase of tension in the 
arterial system as in some cases of hypertrophy of the left 
ventricle of the heart will tend to cause an increase in the 
quantity of urine. 



96 CLINICAL SIGNIFICANCE OF URINE. 

Decreased Quantity of Twenty-four hours. — Leaving the 
cases where the urine in amount exceeds the normal limit 
for twenty-four hours and turning our attention to a de- 
creased amount we find that "at the height of all acute 
febrile diseases the quantity of urine is considerably 
diminished." 

Moreover the quantity of urine passed daily in acute 
disease gives us important indications : "A constant daily 
diminution of the quantity of the urine indicates that the 
intensity of the disease is increasing — a continued loiv 
quantity of the urine {below 800 cubic centimetres, or If 
pints per diem) shoivs that the intensity of the disease has 
not diminished — while a steady increase of the quantity of 
urine shoivs that the force of the disease has been broken" 

— Vogel. 

During convalescence the quantity of urine becomes 

normal or may even exceed that limit. 

In the paroxysms of intermittent fever, i. e., during the 
chill 9 the quantity of urine is not always scanty, nor is it 
always in the acute rheumatism of childhood where there 
is mitral insufficiency or hydremia. 

In typhus fever, a profuse flow of normal urine is some- 
times noticed at the height of the disease. 

Wilson says that in cerebrospinal fever the quantity 
may be much increased even when the fever is active and 
the temperature high. 

The above are the principal exceptions to the general 
rule of the quantity of urine in fevers, and should be 
carefully noted. 

In general all types of violent fever and inflammation 
are likely to be attended by suppression of the urine, as 
scarlatinal nephritis and yellow fever; suppression of 
urine is noted also in the collapse of cholera, in later 



CLINICAL SIGNIFICANCE OF URINE. 97 

stages of organic diseases of the kidneys, and when any 
mechanical obstacle obstructs the flow of urine, as after 
catheterism. The urine is scanty in amount in cirrhosis 
of the liver and in scurvy. Any condition of the heart 
leading to passive congestion of renal veins, by which the 
circulation through the kidneys is impeded, will diminish 
the amount of urine. After copious vomiting or abundant 
watery stools the urine is diminished. 

TJrine in Bright' s Disease. — The quantity of urine is 
diminished in some forms of Bright' s disease : (i.) in the 
early stages of acute parenchymatous nephritis, (ii.) in 
chronic parenchymatous nephritis, (hi.) in interstitial 
nephritis or amyloid degeneration if complicated with 
acute or chronic parenchymatous nephritis according to 
the extent of the parenchymatous complication, (iv.) in 
the last stages of all forms. 

Effect of Drugs on the Quantity of Urine. — Adminis- 
tration of the so-called diuretics, such as acetate of 
potassium, spiritus aetheris nitrosi, etc., will increase the 
quantity of the urine ; also inhalation of oxygen, chronic 
lead-poisoning (irregular transitory polyuria), etc. 

Mineral salts such as those of iron and copper decrease 
the amount of urine ; potassium chlorate when given in 
small doses will increase the amount, but in heavv doses 
will first suppress the urine and then cause an abundant 
flow of bloody albuminous urine. The urine is decreased 
in poisoning from external use of pyrogallic acid (Meisser), 
of aniline compounds, and of atropin (as a collyrium) ; in 
poisoning from phosphorus taken internally. 

The urine is decreased, often to suppression, in poison- 
ing from, or after heavy doses of, cantharides, arsenic, 
carbolic acid, ergot, iodine, mercury, opium. 

Specific Gravity. — In drawing conclusions from the spe- 
7t 



98 CLINICAL SIGNIFICANCE OF UEINE. 

cific gravity of urine the quantity for twenty-four hours 
must he considered. Urine of high specific gravity, (above 
1025), hut small in quantity and heightened in color is 
characteristic of a febrile condition, bearing in mind the 
fact that abstinence from drinking coupled with profuse 
perspiration will cause similar conditions. Urine of high 
specific gravity with increased amount in twenty-four hours, 
especially if continuing for some time, is characteristic of 
diabetes mellitus. Urine of lowered specific gravity and 
increased amount is characteristic of diabetes insipidus. 
(In dropsy or hydremia a large amount of urine low m 
specific gravity is a favorable sign and should not be 
confounded with the conditions obtaining in diabetes- 

insipidus). 

Lastly, and most important to the practitioner, if the 
daily quantity of urine is small and the specific gravity 
lower than normal we have reason to fear uraemia; 
conditions of this kind frequently indicate an alteration 
of the kidneys as observed in Bright's disease. It must be 
observed that the rules given above are for the majority 
of cases ; in diabetes insipidus the specific gravity is not 
always below normal, and cases of diabetes mellitus have 
been observed where the specific gravity was not remark- 
ably high. . . 

Summary for Specific Gravity.— Urine is pathological 
if the quantity for twenty-four hours being collected we 

observe : 

(i.) Specific gravity high, color high, quantity small, 
(ii.) Specific gravity high, color pale, quantity large.^ 
(iii.) Specific gravity low, color of deep tint, quantity 

(iv.) Specific gravity low, urine more or less colorless, 
quantity small. 



CLINICAL SIGNIFICANCE OF UEINE. 99 

The urine for twenty-four hours having been collecte 
on different occasions if we observe : 

(i.) Specific gravity persistently below 1015, suspect 
albuminuria. 

(ii.) Specific gravity persistently below, say, 1008, sus- 
pect diabetes insipidus. 

(hi.) Specific gravity persistently above 1025, color 
pale, suspect diabetes mellitus. 

(iv.) Specific gravity persistently above 1025, color 
high, suspect febrile state. 

EXAMPLE. 

Case 1. — Quantity in twenty-four hours averages 900 
cubic centimetres (^ qt. ). Specific gravity averages 1030 
to 1035. Color always high. The case is one of severe 
fever. 

Case 2. — Quantity in twenty-four hours averages daily 
4800 cubic centimetres (5 qts. nearly). Specific gravity 
averages daily 1025 to 1035. Urine contains sugar. 
Diagnosis, diabetes mellitus. 

Case 3. — Quantity in twenty-four hours averages daily 
3500 cubic centimetres (3|- qts.). Specific gravity averages 
daily about 1015. No sugar found in the urine and the 
case is one of diabetes insipidus. 

Case 4. — Quantity in twenty-four hours averages 600 
cubic centimetres (1^- pints). Specific gravity averages 
1010. The case is one of chronic Bright's disease. 

The above cases are given merely to illustrate principles 
and are by no means intended to serve as sole guides to- 
diagnosis. 

Solids. — If the daily amount of solids is persistently in- 
creased, when at the same time the patient is not living 
on animal food chiefly, or animal broths, destruction of 
the tissues of the body, excessive in nature, may be indi- 



100 CLINICAL SIGNIFICANCE OF URINE. 

cated. In drawing conclusions in regard to the amount 
of solid matters, consider also the quantity of urine daily 
and the specific gravity. 

Case 1. — Quantity, daily, averages 4000 cubic centi- 
metres ; specific gravity, daily, averages 1007 ; solids (es- 
timated by method on page 91,) 56 grammes (862 
grains) . The amount of solids is nearly normal but the 
quantity and specific gravity of the urine are abnormal — 
in other words, the fluid has been increased in amount, 
and either excessive drinking, on the part of the person, 
may be indicated, or, if he be suffering from dropsy or 
hydrsemia, the system is endeavoring to throw off the 
surplus fluid and the condition of the urine is a favorable 

sign. 

Case 2. — Quantity, daily, averages 6000 cubic centi- 
metres (six quarts); specific gravity, daily, averages 
1014; solids, 168 grammes (2,587 grains). The solids 
are largely increased, likewise the fluid, and some form of 
diabetes may be indicated. Testing the urine for sugar, 
in the manner hereafter to be described, would tell us 
which form of diabetes was present, care being taken, if 
sugar be found, to test the urine repeatedly for it for 
sometime afterward. 

If urine of normal or decreased quantity daily, of low 
specific gravity and decreased amount of solids, occur, we 
may suspect some impediment to the secretion of urea 
and have reason to fear the results of retention of urea 
in the body (uraemia). 

We find in most chronic diseases except diabetes, the 
daily amount of solids decreased ; an increase of them is 
then, as a rule, a sign of more favorable conditions, such 
as more active metamorphosis or better nutrition, while, 
on the other hand, an increase of the solid matters at the 



CLINICAL SIGNIFICANCE OF URINE. 101 

height of an acute disease is usually an unfavorable sign, 
because the inanition which always occurs in such cases 
is thereby increased and favored. (Vogel.) 

Lastly, in the case of a patient who, on account of 
a febrile disorder has fasted or taken but little food, we 
must not deem sixty or seventy grammes (924 to 1078 
grains) of solids computed from the amount and the 
specific gravity to be by any means normal, but largely 
in excess. When we say that sixty to seventy grammes 
is the normal amount per diem, we of course presuppose 
ordinary health and ordinary diet. In the case of a per- 
son suffering from an acute febrile disorder, 30 grammes 
(462 grains) will be an average amount, and if this rises 
to 40 or 50 (616 to 770 grains), on a strict and careful 
diet, it is at the expense of the body and is an unfavor- 
able sign. 

In chronic lead-poisoning the amount of solids is 
greatly reduced. 

Summary: (i.) Increased quantity, decreased specific 
gravity, with normal amount of solids, simply means in- 
crease in fluid, and may be physiological or occur in 
certain cases of dropsy; (ii.) Increased quantity, normal, 
increased or even decreased specific gravity with increased 
solids, indicates diabetes; (iii.) Normal or diminished 
quantity, diminished specific gravity and diminished 
amount of solids, means often uraemia, and may occur in 
Bright's disease. 

Color. — Urines of abnormal color may be classified as 

follows : 

I. Nearly colorless : neuroses. 

II. Watery urine and diabetic urine showing slight 
tinge of yellow, which on standing may become darker. 



102 CLINICAL SIGNIFICANCE OF URINE. 

III. High-colored urine, color dark yellow to red or 
even flame red, found in acute febrile disorders. 

IV. Blood-red urine, caused by foreign coloring matter 
or by the passage of blood into the urine. 

V. Dark brown to nearly black urine in (i.) kidney 
diseases, especially haemorrhages, when (ii.) bile coloring 
matters enter the urine, in (iii.) long-continued intermit- 
tent fever. 

VI. Green urine, dirty in hue, in jaundice when bile 
coloring matter is present in the urine — so-called " ic- 
teric" urine. 

VII. Dirtv-blue urine chiefly in cholera and typhus 

(see page 104). 

In familiar language, the abnormal colors shown by 
urine or its sediments may be classified as follows : 

" Smoky" colored urine : due to presence of blood. 

White urine : due to presence of pus, spermatozoa or 

chyle. 

Black urine : due to presence of (i.) melanin, or to (ii.) 

drugs, or found in (iii. ) renal diseases. 

Brown or green urine : due to presence of bile. 

Pale urine : in chlorosis, anaemia, diabetes, atonic gout, 

hysteria. 

High-colored : in (i.) organic disease of the liver, (ii.) 

febrile states or inflammations. 

"Milky": due to deposits of phosphates or white 
urates. See also White Urine. 
Influence of Drugs on Color of Urine : 

Carbolic acid, externally or internally, darkens the urine. 

Sulphuric acid, creosote, arseniuretted hydrogen cause 

black tint. 

Inunction of tar causes black tint. 
Gallic and tannic acids cause dusky hue. 



CLINICAL SIGNIFICANCE OF URINE. 103 

Strong coffee darkens the urine. 

Indigo : greenish blue. 

Aloes : deep red. 

Madder, campeachy wood, mulberries : red. 

Alizarin : rose-colored. 

Gamboge, senna, logwood, picrotoxin : yellow. 

Santonin: rich golden yellow in acid urine; orange 

red in alkaline. 

Rhubarb: deep gamboge yellow changed to red on 

addition of ammonia. 

Resin : grayish yellow. 

In regard to the dark color of the urine, caused by 
carbolic acid poisoning, Eeichert says that in 56 such 
cases he found 20 per cent were colored dark ; this color 
may appear in two hours or so, and last several days and 
at times is only perceived by holding the urine to the 
light. According to Kirmisson, if the urine have a dark 
or a dark green hue, care should be taken about continu- 
ing the use of the acid. In chlorate of potassium 
poisoning the urine may be colored black. 

In a case of poisoning by duboisin, recorded by Berner, 
the urine was as colorless as water. 

In a case of poisoning from the external use of car- 
bolic acid, reported by Weiss, the urine first became dark 
colored, but subsequently lost this coloration and became 

chylous. 

In two cases of poisoning from the external use of 
aniline chlorhydrate for psoriasis, the urine was colored 
dark red. (Lailler.) 

In a case of poisoning from the external use of pyro- 
gallic acid, the urine became dark brown. (Neisser.) 

The urine of a patient suffering from a bum may be 
brownish green, from presence of bile pigments. 



104 CLINICAL SIGNIFICANCE OF URINE. 

In cases of chronic lead-poisoning the urine, after 
ansemia or icterus has set in, may become brown from 
presence of blood pigment ; subsequently, abundant and 
clear. (Gautier. ) 

According to Robin (Essai d' Urolgie Olinique) there 
are three varieties of blue urine : 

I. Urine blue at time of emission. 

II. Urine becoming blue after standing several hours. 

III. Urine containing blue layers. 

The first variety, that blue at time of emission, is very 
rare, and only two cases have come under his observation. 

He has seen eight cases of the second variety, in 
typhoid fever, and deems blue urine in this disease a 
favorable sign. 

In chronic affections of the spinal cord he has seen 
two cases of the third variety. 

Transparence. — We have learned that normal urine 
should be clear with the merest cloud of mucus, etc., 
settling to the bottom on standing. 

If the urine is clouded within eight to ten hours after 
it is passed or at the time it is passed, it contains those 
substances which after long standing form a sediment, 
(see Sediments) and is pathological. 

We caution physicians against inferring that, because 
the urine is transparent, it is necessarily normal ; but, on 
the other hand, distinct turbidity always allows us to con- 
clude that there is some abnormal condition. Urine may 
be perfectly clear when first passed, but on cooling throw 
down a sediment of urates, especially in cold weather. 
Opaque urine which on heating and application of acids 
becomes turbid may contain albumin or pus. 

Urine turbid when first passed often contains pus. A 
whitish sediment in urine may be phosphates or possibly 




CLINICAL SIGNIFICANCE OF UKINE. 105 

urates ; heat clears urates ; a drop or two of nitric acid 
clears phosphates, the urine after such treatment appear- 
ing normal. 

Consistence. — Hippocrates said that "bubbles main- 
tained upon the top of the urine signify a disease of the 
reins and, likewise, its long continuance," a fact which 
Dr. Southey, in his Lumleian Lectures on Bright's Dis- 
ease, remarks, remained unimportant until the end of the 
last century, when it was ascertained that albuminous 
urine held a froth of bubbles on its surface. 

Hassall, in reviewing these statements affirms that the 
persistent presence of air-bubbbles on the surface of urine 
may be noted in most cases of albuminuria, but that it 
does not follow that all urine which froths is albuminous ; 
he thinks the frothing in some cases to be connected with 
the high density of the urine ; in others, with its feeble 
acidity or alkalinity; in others, with an excess of mucus. 

In general, the occurrence of retained and persistent 
air bubbles on the surface of urine is nearly always of 
pathological significance. Kirk thinks that fatty or oily 
matter in the urine prevents the formation of bubbles. 

Pathologically, we find the urine viscid, when contain- 
ing pus in large amount. 

Urine containing bile foams easily and profusely. 

In urine containing sugar or albumin, any foam which 
may gather will remain longer than in the case of healthy 
urine. 

When the urine has become strongly alkaline and con- 
tains at the same time pus, it will often become so stringy 
and tenacious as not to drop from the tube or vessel. 

Chylous urine (urine containing chyle) is often jelly- 
like in consistency. 

In certain cases of fibrinuria (urine containing fibrin) 



106 CLINICAL SIGNIFICANCE OF URINE. 

the urine soon after being passed coagulates in the vessel. 
King mentions having seen several specimens of urine 
white in color and of creamy consistence forming a thick 
idly-like mass shortly after being voided ; he found in 
such urine no fat of any kind, but an incredible amount 
of mucus and phosphates. 

Odor —If the odor of urine be ammomacal and repul- 
sive it may be merely stale, hence ascertain how long ft 
has stood ; urine on standing, especially in summer, or in 
a warm room, will become alkaline in time, if exposed to 
the air, and take on a disgusting odor. If this ottensive 
odor is noticeable soon after the urine is passed in o a 
clean vessel, then the urine is pathological, indicating 
decomposition of it within the body. . . 

Such putrid, offensive urine of an alkaline reaction is 
found in affections of the brain and cord and in certain 
genito-urinary diseases, especially in advanced cases of 
severe cystitis, or destructive renal diseases ; m certam 
renal diseases the odor is often gangrenous. 

Fresh diabetic urine smells sweetish ; stale, like sour 
m ilk • purulent and sanious discharges in the urine cause 
a stale, offensive odor like that of tainted flesh. 

Certain articles of diet, as asparagus, cauliflower, garlic, 
onions, and certain drugs, as turpentine, valerian, asa- 
fcetida, castor oil, copaiva, cubebs, sandal-wood oil, com- 
municate certain peculiar odors to the urine. 

Reaction.-The normal reaction of the urine is known 
to be slightly acid, i. e., turns blue litmus slightly red ; on 
Inding some time "acid fermentation," so-called, sets m 
and the urine becomes strongly acid, i. e., turns blue 
litmus paper bright red, then subsequently becomes 
strongly alkaline, after the so-called "alkaline fermenta- 
tion" sets in. 




CLINICAL SIGNIFICANCE OF UEINE. 107 

Before the physician decide upon the clinical signifi- 
cance of the reaction of the urine he must ascertain how 
long the urine has been standing, and if over twenty-four 
hours its reaction is not always a reliable guide. 

Two conditions of the urine are of clinical significance: 

I. Strong acidity, when freshly passed. 

II. Alkalinity within twenty-four hours. 

Diseases in which the Freshly Voided Urine is Strongly 
Acid : 

I. Fevers, inflammations, especially liver, heart, lungs. 

II. The urine may be strongly acid and yet no acute 
febrile disturbance be present; in this case the forma- 
tion of sediments and concretions is to be feared, es- 
pecially of uric acid. 

It is difficult to increase sensibly the acidity of urine 
by administering acids ; but if it is desirable that the urine 
be kept steadily alkaline 300 or 400 grains daily of bi- 
carbonate of soda or potash, or of the acetate or citrate of 
either of these bases, will bring about the desired results. 

Diseases in which the Urine may become Alkaline within 
twenty-four hours. 

I. Debility, exhaustion from over-work, care, anxiety, 
etc. 

II. Anaemic states following subacute rheumatism and 
gout. 

III. Chlorosis. 

IV. Functional derangements of the liver with dimin- 
ished acretion of bile ; dyspepsia, chronic vomiting. 

V. Many acute diseases, as typhus, scarlet fever, enteric 
troubles, pneumonia, and convalescence from same. 

VI. Pulmonary complaints, as in phthisis; long con- 
tinued respiration of impure air. 

[The alkalinity in the cases (I.-VI.) is due to the 



108 CLINICAL SIGNIFICANCE OF UKINE. 

presence of fixed alkali so-called, i. e., potash or soda not 
ammonia ; such urine shows no tendency to contain gravel 
or calculi and is not associated with inflammation of the 

urinary passages J. 

VII. Local affections of mucous membrane of lower 
urinary passages : (i.) Bladder troubles as paraplegia with 
paralysis of bladder, morbid growths, calculous concre- 
tions, cystitis ; (ii.) obstinate urethral stricture, enlarged 

prostate. . 

Conditions which interfere with the complete emptying 
of the bladder render the urine alkaline from development 
of ammonium carbonate into which urea is changed (by 
the presence of a " ferment" called by Bechamp, nephro- 
zymase), when for any cause the urine either wholly or in 
part is retained in the bladder. 

Urine which is alkaline when first passed, or very soon 
thereafter, from ammonia is irritating to the mucous 
membrane and leads to cystitis. Such urine always con- 
tains a sediment of phosphates (amorphous lime-phosphate 
and ammonio-magnesium, or triple phosphate, together 
with spheres and dumb-bells of ammonium urate which 
tend to gather together into masses). It is ammomacal, 
often putrescent in odor. 

It is important that the physician be able to distinguish 
between urine alkaline from presence of a fixed alkali and 
urine alkaline from presence of ammonia. 

Urine alkaline from fixed alkali. 

I. Bland and innocuous to the mucous membranes. 

II. No inflammation of urinary passages. 

III. Pleasant, often aromatic odor. 

IV. Seldom contains sediment; if any, amorphous 

phosphate of lime. 

V. Turns red litmus paper permanent blue. 



CLINICAL SIGNIFICANCE OF URINE. 109 

Urine alkaline from ammonia. 

I. Irritating to the mucous membranes. 

II. Inflammation of urinary passages. 

III. Ammoniacal or offensively putrescent odor. 

IV. Contains abundant deposits, phosphates (amor- 
phous and triple). 

V. Turns red litmus paper blue which fades to red 
again on exposure for a short time to air. 

Cautions. — Before deciding that the urine is alkaline 
from ammonia be sure, (i.) that it is alkaline when first 
passed, (ii.) that the vessel containing it was perfectly 
clean. Always remember (i.) that stale urine which has 
been exposed to the air becomes, in time, ammoniacal, 
(ii.) that if a vessel contain a little stale urine fresh urine 
passed into it rapidly becomes ammoniacal. The phy- 
sician must see that the chamber vessels and urine glasses 
of the patient are not merely emptied but thoroughly 
washed so that every trace of the stale urine is removed. 

Agents which exert an influence on various conditions 
of the urine. 

I. Solid matters in the urine are increased by appreci- 
able doses of digitalis, belladonna, colchicum, carbonate of 
potassa, white Rhine- wine and many other agents. Master- 
man has shown [Lancet, October, 1880,) that beef tea is 
analogous in its chemical analysis to urine except that it 
contains less urea and uric acid. 

II. The solids are decreased in the urine by citrate of 
quinia and iron, ammonio-citrate of iron with quassia, 
alcohol, beer, coca, tea, coffee, and Paraguay tea ; also by 
opium, morphia, conium, calabar-bean, hyoscyamus, can- 
abis. It is necessary to exercise some care in decreasing 
the solids in the urine by use of the last named drugs 
owing to their action on the nervous system. 



110 CLINICAL SIGNIFICANCE OF URINE. 

III. The fluids of the urine are increased by sweet spirits 
of nitre, beer, gin, turpentine, whisky, coffee without sugar 
or milk, large draughts of soft water, and by other agents 
called diuretics. 

IV. The fluids are diminished by conia, citrate of quinia 
and iron ; iron, copper, and ammonio-citrate of iron with 
quassia ; arsenic and cantharides in appreciable doses may 
almost wholly arrest the flow of urine. 



NORMAL CONSTITUENTS. 

UREA (NH 2 ) 3 C0. 

Urea is a substance composed of one part carbon, four 
parts hydrogen, two parts nitrogen, and one part oxygen — 
by weight ; its most important constituent from a clinical 
point of view is nitrogen, since five-sixths of all the nitrogen 
absorbed in the food passes out of the body as a component 
part of this chief constituent of normal urine. Pure 
urea is white, semi-transparent, and crystalline (four-sided 
or circular crystals), odorless, of a bitter, cooling taste, 
somewhat like that of nitre. Urea is very soluble in 
water and is therefore never seen in the urine ; to obtain 
it in the pure state described above, various chemical 
processes are required. 

The amount of urea present in urine is indicative to a 
certain extent, of the wear and tear of the system— taking 
into careful consideration circumstances of diet, habit, 
etc. The normal amount of urea passed in twenty-four 
hours is from 25 to 40 grammes (385 to 600 grains). 

According to Brouardel, the quantity of urea depends 
upon the integrity of the hepatic cells and the greater or 
less activity of the hepatic circulation. 









CLINICAL SIGNIFICANCE OF URINE. Ill 

Tables of Harley : 

Normal urine of twenty-four hours : 

Boy, 18 months, 8-12 grammes, - 124.0-186.0 grams. 

Girl, " 6-9 " - 93.0-139.5 « 

Man, 27 years, 25-35 " - 387.5-542.5 " 

Woman « 20-30 " - 310.0-465.0 « 

Proportion of urea according to weight : 

Boy, 0.4 gramme, - - - 6.2 grains to the pound. 

Girl, 0.35 " - - - 5.4 « 

Man, 0.25 " ... 3.8 " "' « 

Woman, 0.20 « - - - 3.1 " " « 

These tables show that children, relatively, excrete more 
urea than adults, and that men excrete absolutely and 
relatively, more than women. The " average man " then 
excretes about 3.8 grains of urea to the pound of weight — 
the average woman, 3.1. 

Purely animal diet will increase the daily amount of 
urea to from sixty to ninety grammes ; purely non-nitroge- 
nous diet will reduce it to less than fifteen. Hence in 
diseases where there is excess of urea animal diet is strongly 
contraindicated ; in diseases where it is deemed advisable 
to increase it, animal diet is indicated. 

Diet which may increace the amount of Urea: 

I. Animal food, especially lean meat ; animal soups. 

II. White of egg, milk, jellies, coffee without sugar. 

Diet which may decrease the amount of TJrea. 

I. Amylaceous foods : tapioca, arrow root, sago. 

II. Sugar. 

III. Oleaginous foods : Cream, cod-liver oil, etc. 

The latter diet is indicated when there is excess of urea 

in the urine ; if the patient crave meat give him meat fat. 

Vegetables may be allowed when it is desired to decrease 




112 CLINICAL SIGNIFICANCE OF URINE. 

the amount of urea ; a purely vegetable diet will diminish 

it one-third. 

A careful distinction must be drawn between a dimin- 
ished excretion of urea and a diminished formation of it ; 
in some diseases urea although formed in the body is held 
back and does not appear in normal amount in the urine, 
in others it is scantily formed in the body. When the 
condition called urcemia is present there is but little urea 
to be found in the urine, yet it would not be advisable to 
put the patient on an animal diet since such urea as is 
formed is not readily excreted. When formed by the 
system, and through any interruption of the eliminating 
function of the kidney, accumulated in the blood, it is 
called by some authors, " a powerful irritant poison, rapidly 
inducing convulsions, coma and death/' 

Substances which increase urea in the urine.— Water, 
common salt, atropin, cubebs, cantharides (in appreciable 
doses). Copious draughts of water aid in the elimination 

of urea. 

Substances which decrease urea in the urine.— Digitalis, 
benzoic acid, acetate of soda, phosphate of soda, colchicum, 
tonics, especially citrate of iron and quinine. 

Clinical significance of urea.— The diseases in which 
urea is increased in the urine are : 

I. Acute febrile states with emaciation (except yellow 

fever). 

II. Exanthemata. 

III. Inflammatory affections. 

IV. Some nervous diseases. 

V. Diabetes insipidus and mellitus. 

VI. Atrophy from dyspepsia (in children). — Athrepsy, 

Parrot and Kobin. 

VII. Diffuse bronchial catarrh (without fever). 



* CLINICAL SIGNIFICANCE OF URINE. 113 

VIII. Phosphorus poisoning. 

The increase of urea in acute febrile disorders, as 
typhoid fever, continues up to the acme of the attack, 
reaching anywhere from 50 to 80 grammes for the twenty- 
four hours ; when the fever diminishes there is less meta- 
morphosis of tissue, less "wear and tear," less urea. 
During convalescence the amount gradually returns to 
normal. 

The above mentioned course is the general rule in the 
majority of instances ; individual exceptions are some- 
times noticed. 

In intermittents the increase in urea begins before the 
chill ; in other words, the increase in urea shows the coming 
of the paroxysm before the clinical thermometer can detect 
any rise in temperature* 

In typhoid fever we find urea enormouslv increased; 
Harley cites a case where 78 grammes (1209 grains) were 
passed in twenty-four hours. 

Vogel found the amount in this disease at the height to 
fluctuate between 40 and 55 grammes (617 to 847 grains) ; 
as the fever diminished it fell to 20 grammes (308 grains) 
to rise to normal with convalescence. 

We find urea increased in typhus, remittent fevers and 
exanthematous diseases, but not generally to such an 
extent as in typhoid fever. 

In inflammations, as well as in fevers, the amount is 
increased. A case of croupous pneumonia is cited where 
the amount of urea on one day reached 80 grammes 
(1240 grains). 

In pneumonia, daily averages of from 40 to 60 grammes 
(617-925 grains) and even 70 grammes (1080 grains) 
are found. 
8f 



114 CLINICAL SIGNIFICANCE OF UKINE. 

The practitioner will do well to remember that urea is 
derived from the breaking up of the nitrogenous tissues 
of the body; that during the height of acute diseases 
this breaking up is abnormally increased, hence the 
amount of urea is abnormally increased in the urine. 

It stands to reason, then, that in such diseases knowl- 
edge of the fact that urea is diminishing is, as a general 
rule, knowledge of the fact that the disease is abating. 

After the height of an acute malady has been reached 
the amount of urea will often fall below normal, to rise 
again as convalescence ensues. 

When, previous to an acute malady, there has been a 
state of impaired nutrition, or, in a fever when there 
has been much sweating, we must not expect to find 
remarkable increase of urea. 

In pyaemia the amount of urea is greatly increased; 80 
grammes (1234 grains) a day have been known. 

In many nervous diseases we find the daily amount of 
urea increased, among which epilepsy — especially during 
and after the attack — chorea, and progressive muscular 
atrophy. 

In diabetes mellitus 70 grammes (1080 grains) in 
twenty-four hours have been found, and in insipidus 84 
grammes (1296 grains). 

Diseases in which TJrea is Decreased in the Urine. 

I. Long-continued organic diseases. 

II. Chlorosis. 

III. Paralysis. 

IV. Cholera. 

V. Yellow fever. 

VI. Ovarian tumor and uterine cancer. 

VII. Before paroxysms of gout and of asthma. 

We find urea decreased in amount in the urine of per- 



CLINICAL SIGNIFICANCE OF URINE. 115 

sons suffering from those chronic complaints " which are 
accompanied by diminution of the tissue metamorphosis 
or of the nutrition. During intercurrent exacerbations, 
hectic fever, etc., it is increased again." 

A distinction must be made between decrease in urea 
due to decreased tissue metamorphosis and that due to 
inability on the part of the body to get rid of it when 
formed. 

We find urea retained in the body in dropsy and in the 
condition known as uraemia. 

In vellow fever the uraemic condition is found and 
amazingly small amounts of urea may be voided. 

When the kidneys are disordered urea is decreased, 
thus we find in Bright's disease a deficiency of this sub- 
stance in the urine. 

We find urea decreased, also, in paralysis, anaemia, 
chlorosis, ovarian tumor and uterine cancer (Thudichum), 
Addison's disease. (Rosenberg. ) 

In acute yellow atrophy of the liver, the substances 
known as leucin and tyrosin replace urea in the urine 
and but little of this last substance is found. 

In cholera, urea seems not to be formed in the body. 
(Beale.) 

The inferences to be drawn from the variations of urea 
are as follows : The urine of twenty-four hours having 
been examined, if the acme of a disease from other indi- 
cations seems to have passed and the amount of urea be 
still largely in excess, the prognosis is unfavorable ; if, 
however, the amount of urea decreases from day to day 
the prognosis is favorable. 
■ In Bright's disease, if the amount of urea remains 

* 

about normal a more favorable condition is indicated 
than if the amount be decreased. In any disease, as 



116 CLINICAL SIGNIFICANCE OF URINE. 

cholera, where a diminished amount of urea has been 
found, a gradual or rapid increase is a favorable sign. 

If for a long time much less urea than normal is 
passed with the urine, we may have reason to fear that 
uraemia may result from the retention of urea in the 

blood. (Vogel.) 

If, in dropsy, diuretics have been given, or for any 
other reason the kidneys manifest increased activity, the 
amount of urea will be largely in excess. 

The physician must carefully bear in mind the fact 
that in strongly ammoniacal urine part of the urea has 
been converted into carbonate of ammonium, hence the 
amount of urea found in such urine "is no criterion of 
the amount of urea produced." 

Estimation of Urea.— Hypobromite Process.— One of 
the best methods of estimating urea by the use of hypo- 
bromite, is that of Yvon, which is a modification of the 
Knop-Hueffner method; with the necessary apparatus 
the analysis can be made in five or six minutes at the 
patient's bedside. The apparatus consists of a long, 
wide, bell-mouthed beaker and a glass tube called an 
ureometer, 40 centimetres long and 1 centimetre in diam- 
eter. The ureometer is divided into two compartments 
by a glass stop-cock placed toward its upper quarter, 
which allows a communication between the two compart- 
ments to be established or suppressed at will. Commenc- 
ing at this stop-cock, the tube is graduated, above and 
below it, into cubic centimetres and tenths of the same. 
The lower part of the tube is the longest, from its ex- 
tremity to the stop-cock, and is designed to be placed into 
a mercury jar, as hereafter described. The standard solu- 
tion employed consists of solution of caustic soda, (36°), 
30 grammes, dissolved in distilled water, 125 grammes, to 



CLINICAL SIGNIFICANCE OF URINE. 117 

which add, when cold, bromine, 5 grammes, and agitate 
strongly. Allow it to rest for some time, and, after 
decantation, a fine yellow, clear, transparent fluid remains 
which has to be frequently renewed, as it loses considera- 
ble of its strength in a very short time. By keeping the 
solution of caustic soda, separately, this preparation may 
be made in small quantity, whenever required, by adding 
to any given amount of it the proper proportion of 
bromine. As a ted liquor of this standard solution, 1 
gramme of pulverized urea, well dried by a prolonged 
sojourn under a bell glass with sulphuric acid, is dissolved 
in distilled water so as to have 5 cubic centimetres of 
the solution equal to 1 centigramme of urea. After the 
action of the standard solution of hypobromite of soda, 
upon this solution of urea, 37 divisions of the tube or 
|_t. of a cubic centimetre of gas will correspond to one 
centigramme of urea. Ten cubic centimetres of the non- 
albuminous urine are diluted with distilled water to make 
a volume of 50 cubic centimetres, and of this diluted 
urine from 1 to 5 cubic centimetres are operated upon, 
according to its richness in urea. Polyuric urine requires 
no dilution. We must alwavs endeavor to have no more 
than forty divisions of gas, in order not to increase 
too greatly the volume of the standard solution to be em- 
ployed, and the dimensions of the column of liquid. The 
method of proceeding is as follows : Open the stop-cock 
and plunge the inferior extremity into the jar filled with 
pure mercury, until this has arisen to a level with the 
lower part of the superior compartment ; then close the 
stop-co^k, raise the tube (but not entirely out of the 
mercury,) the inferior compartment of which is filled 
with the mercury, and maintain it in this position by 
means of a strap or collar, which forms part of the com- 



118 CLINICAL SIGNIFICANCE OF URINE. 

plete apparatus. Into the upper apartment place from 1 
to 5 cubic centimetres of the diluted urine, open the 
stop-cock, and carefully make the fluid flow into the 
inferior compartment, closing the stop-cock before any 
air can pass along with it. Wash the receptacle at the 
superior part of the tube with several drops of distilled 
water, and carefully pass this into the lower apartment, 
by means of the stop-cock, as in the previous instance. 
This done, place in the upper receptacle five or six cubic 
centimetres of the standard solution, and, as in the first 
instance, make it pass into the lower apartment, raising 
the tube a little should this be necessary. Agitate by an 
up-and-down motion, but without removing the tube en- 
tirely out of the mercury, having the stop-cock closed, of 
course. Decomposition occurs immediately, the urea is 
separated into water, nitrogen, and carbonic acid gas ; the 
last being absorbed by the excess of alkali, nitrogen alone 
remains in the tube. To render the mixture more exact, 
raise the tube, close the lower orifice, while this is under 
the mercury, with a finger, and shake it; then carefully 
replace it in the mercury. The liquid soon becomes lim- 
pid when all the gas has collected together, and the 
amount of gas may be read off on the graduated divisions 
at the level of the fluid remaining in the lower compart- 
ment. The measurement of the gas is made in a beaker 
filled with water, being careful properly to place the sur- 
face of the liquid in the tube on a level with that of the 
fluid in the beaker. For instance, 5 cubic centimetres of 
the diluted urine have been operated upon, and we find 
22 divisions of gas produced, and as 5 cubic centimetres 
of the standard solution represents 1 centigramme of 
urea, we have ff of a centigramme of urea. But the 
urine has been diluted to five times its volume with water, 



CLINICAL SIGNIFICANCE OF URINE. 119 

from which we can readily conclude that 1 cubic centi- 
metre of the original undiluted urine contains ff of a 
centigramme of urea. If 800 cubic centimetres of the 
urine are passed in twenty-four hours we have 800 X 22 
-4- 37 = 4.754 grammes of urea in 800 cubic centimetres 
of urine; or 5.945 grammes of urea in 1000 cubic centi- 
metres of urine. 



SODIUM CHLORIDE. 

(Common Salt.) 

Common salt is a normal constituent of urine, its 
chemical name being sodium chloride and symbol NaCl, 
one part sodium and one part chlorine. 

According to Vogel the healthy adult passes 10 to 13 
grammes per diem (154 to 200 grains). 

Salt is soluble, therefore never seen in the urine. 

The excretion of salt depends chiefly upon the activity 
of the kidneys ; the salt excreted comes in the main from 
salt ingested in food, although if no food be taken, a 
small amount of salt will be excreted. 

Salt is increased in the urine, then, by food in general, 
especially that containing salt and by copious draughts 
of water which dissolves it and aids in its elimination; 
salt is decreased in the urine by lack of food and of 

water. 

A great decrease or an entire absence of salt is of 

interest to the physician. 

Diseases in which Salt is Decreased or Absent. 

I. Acute diseases; especially inflammation with ex- 
udation. 

II. Cholera. 

In inflammations attended by exudation salt may be 



120 CLINICAL SIGNIFICANCE OF URINE. 

absent from the urine; for example, in pneumonia when 
the lung becomes hepatized, salt may be absent for two or 
three days; resolution occurring it reappears. When 
absent from the urine, salt may be found in the sputa. 
(Beale.) Salt has a tendency to centre around a point 
where inflammatory changes are taking place, hence 
diminished in the urine. (Beale.) 

In acute articular rheumatism, sudden absence of chlo- 
ride with appearance of albumin, may indicate a coming 
attack of pericarditis. 

In cholera, salt is greatly diminished ; " an increase in 
salt in the urine during an attack of cholera is a most 
reliable symptom of recovery." (Buhl.) 

In inflammatory diseases and in cholera the physician 
may obtain aid in making a prognosis by testing the 
urine for salt ; if absent or greatly diminished for any 
length of time it is an unfavorable sign. 

Diseases in which Salt is Increased in the Urine. 

I. Intermittens, during the chill and fever (twenty- 
four hours amount normal). 

II. Progressive muscular atrophy. (Bamberger.) 
The following summary of Vogel is of interest : 

"In all acute diseases & progressive diminution of salt 
shows an increase, and a progressive increase of salt a 
diminution of the disease ; if the amount fall below 0.8 
gramme daily we conclude that there is considerable 
intensity of the disease." 

In chronic diseases the amount of salt is a tolerably 
accurate measure of the digestive power of the patient; 
an abundant amount (10 to 16 grammes daily) permits 
us to infer that digestion is good ; a small amount (below 
8 grammes) shows a weak digestion, provided there are 
no watery dejections or any other moderate exudation. 



CLINICAL SIGNIFICANCE OF URINE. 121 

SULPHURIC ACID. 

In Combination Forming Sulphates. 

Normal urine contains sulphuric acid, in daily amount 
averaging from 1 \ to 2^ grammes, and in combination 
with sodium and potassium* forming the sulphates of the 
latter. The ingestion of sulphur, sulphides, or sulphates 
contained in articles of diet will increase the amount of 
sulphates in the urine but under no circumstances is 
there ever a deposit of them. The clinical significance, 
if any, of the sulphates is but imperfectly understood ; if 
their amount increase in acute febrile disorders when 
little or no food is taken decomposition of the elements of 
the body is indicated. 

The sulphates are increased in : 
(i.) Progressive muscular atrophy. (Bamberger.) 
(ii.) Phosphorus-poisoning. (Cazeneuve.) 
(iii.) Diseases of the brain. (Bence Jones.) 
The sulphates are decreased in : 
(i.) Chronic renal disease. (Heller.) 
(ii.) Carbolic acid poisoning. (Baumann.) 
The author has observed one case of Bright's disease, 
(chronic form) in which no sulphates could be detected 
by the ordinary methods; examining the urine of a 
patient who had had a considerable number of hypo- 
dermic injections of phenic (carbolic) acid, (Declat 
method) he found the sulphates about normal in amount. 

PHOSPHORIC ACID. 

In Combination Forming Phosphates. 

The amount of phosphoric acid, which in combination 
with potassium, sodium, calcium and magnesium, is passed 

* Strictly speaking, with the oxides. 




122 CLINICAL SIGNIFICANCE OF URINE. 

daily in the urine averages from 2.5 grammes to 3 
grammes daily (38 to 46 grains). Two-thirds of this 
amount is contained in the phosphates of sodium and 
potassium (alkaline phosphates), and the remainder in 
the earthy phosphates, i. e.„ those of calcium and mag* 

nesium. . 

It has been customary to attach considerable impor- 
tance to a deposit of earthy phosphates-which will occur 
when the urine becomes alkaline, (see Deposits)— whereas 
from the very reason that deposits of these substances 
. depend upon an alkaline condition of the urine they 
rarely have a grave import, except when composed of the 

triple phosphate. ;■■ ., J ; 

Persistent excessive elimination of phosphoric acid with 
or without deposition of the earthy phosphates, is generally 
associated with grave constitutional disturbances. (Kalte.) 
Diet which may Increase the Amount of Phosphates in 

the Urine : . ■ 

Beef, bread, potatoes, milk. 
Diet which may Decrease the Amount of Phosphates: 

Starchy, saccharine, and oleaginous foods. 
Diseases in which the Total Amount of Phosphates may 

be Increased: 

I. Inflammatory diseases of the nervous system; nerve 

lesions in general— injuries to the head. 

II Acute febrile disorders (not invariably). 

III. Bright's disease and cholera (if obstruction be 
removed by which they have been retained). 

IV. Phosphorus-poisoning. 

[In rachitis, according to Seeman, phosphates actually 
diminished in the urine.] 



CLINICAL SIGNIFICANCE OF UKINE. 123 

Diseases in which the Total Amount of Phosphates may 
be Decreased: 

I. Eenal and intestinal diseases. (Brattler.) 

II. Intermittent fever, during the interval. (Hax- 
thausen. ) 

III. Chronic diseases of the brain, exhaustion stage of 
mania, acute dementia, delirium tremens. 

IV. Severe pneumonia. 

V. Gout and arthritis deformans. 

(An increase in the amount of phosphates in these 
diseases is therefore favorable.) 

Diseases in which the Earthy Phosphates may be especially 
Increased in the Urine : 

I. Mollities ossium. 

II. After severe burns. 

III. Nervous exhaustion from severe study and loss of 
sleep. 

IV. Diabetes. 

V. Tertiary syphilis. 

VI. Cerebral and spinal tumors; osseous tumors. 

VII. Cancer. 

VIII. Caries. 

IX. Meningitis. 

X. Progressive muscular atrophy, (magnesium phos- 
phate chiefly.) 

The physician must carefully bear in mind the fact 
that when urine is acid in reaction, it may contain an 
excessive amount of phosphates and yet contain no deposit; 
nor is a deposit of them necessarily a sign of excessive 
amount, since alkalinity of the urine will cause them to 
appear even when not in excessive amount. 

When we have to deal with the persistent elimination 
of phosphoric acid in excessive quantities very distressing 



124 CLINICAL SIGNIFICANCE OF URINE. 

constitutional symptoms are asoociated with its discharge. 
The symptoms vary considerably in individual cases, but 
they are all more or less characterized by great nervous 
irritability, derangements of digestion, great emaciation, 
severe aching pains in the back and loins, especially affect- 
ing the pelvic viscera. (Ralfe.) When these symptoms 
are present and the urine is copious, of acid reaction and 
clear, an estimation of the quantity of phosphoric acid 
may throw new light on an otherwise doubtful case. 

When it is remembered that persistent elimination of 
phosphoric acid is sometimes a forerunner of diabetes, 
especially insipidus, the importance of an early recogni- 
tion of the condition may well be comprehended. In- 
creased amount of phosphates in the urine is often asso- 
ciated with troublesome eye affections ; it is also found 
in connection with tardy reparation of wounds and is apt 
to render bones more fragile, causing fractures and tardy 
union. The physician, therefore, should not plume him- 
self on the fact that as the urine is clear and free from 
deposit it is therefore clinically meaningless, until he has 
proved that the phosphates are not persistently in great 
excess. When the urine is alkaline and "whey colored" 
from a heavy deposit, the attention of both patient and 
practitioner will naturally be called to it. See Deposits. 

URIC ACID. 

In Combination Forming Urates. 

TJric acid in combination with sodium, potassium, am- 
monium, or (rarely) calcium, forming the urates of 
sodium, potassium, etc., is a normal constituent of urine. 
About If grammes of urates (27 grains) are voided daily. 



CLINICAL SIGNIFICANCE OF URINE. 125 

Diet which may Increase the Amount of Urates : 

Nitrogenous foods : lean meat, etc. Port wine, beer. 

In other words, "high living" is often responsible for 
an increased amount of these substances. 

If the urine is not too acid in reaction it may carry an 
increased amount of urates without showing a deposit of 
them ; in such cases the specific gravity will be compara- 
tively high, 1020 or 1025. To estimate the amount of 
uric acid passed daily in combination with its bases is not 
at all convenient for the physician. For further consid- 
eration see Deposits. 

Increase but not Necessarily Deposit of Urates in Dis- 
ease. 

The advice of Coignard in regard to uric acid in the 
urine is worth remembering: "In a large number of 
persons no actual disease can be demonstrated but they 
are constantly ailing, are more irritable than their fellows, 
especially if their hygienic surroundings are bad, their 
life idle or their occupations sedentary. In such cases it 
is necessary to estimate the amount of uric acid combined 
and forming urates, and if there be excess, correct the 
diet, give them plenty of exercise and a methodical alka- 
line treatment." 

According to Ealfe, uric acid is eliminated in excess, 
(i. e., in combination with urates) but not necessarily 
deposited from the urine under two conditions : 

1. Uric acid in excess usually attended by a diminution 
of the other urinary constituents, (true lithaemia) ; this 
occurs chiefly in diseases of the liver, such as acute yellow 
atrophy, cirrhosis, and cancer. In scurvy an excess of 
uric acid is generally observed with a diminution of urea 
and the alkaline phosphates. 

2. Uric acid in excess attended by an increase of the 



126 CLINICAL SIGNIFICANCE OF UBINE. 

other urinary constituents ; this may occur in functional 
derangements of the liver, especially those brought about 
by disturbance of the "nitrogenous equilibrium," by the 
ingestion of too much animal food. It may happen as a 
condition antecedent to the development of phthisis or 
cancer and sometimes of diabetes, or preceding the out- 
break of such constitutional conditions as syphilis, scrof- 
ula, and of gout in its early attacks. 

In order to ascertain whether uric acid is in excess its 
amount must be estimated, i. e., the total amount com- 
bined with sodium, potassium, etc., forming the urates. 

Dr. E. A. Cook {British Med. Journal, April 15, 1882,) 
gives a method for approximately estimating the amount 
-of uric acid in normal urine and the results of his process 
go to show that the normal amount of uric acid excreted 
by a healthy adult is much greater than has hitherto 
been supposed; not less than ten grains and seldom less 
than twelve grains being the quantity discharged m twenty- 
four hours. His method is the following: Take 300 or 
400 cubic centimetres of the urine and add a few drops 
of strong solution of caustic soda, enough to render it 
decidedly alkaline ; allow the precipitate of phosphates to 
subside and pour off 100 cubic centimetres of the clear 
solution ; add to this clear solution about 4 cubic centi- 
metres of a solution of zinc sulphate, 1 to 3 strength. 
The solution of zinc sulphate renders blue litmus red and 
it must be added to the urine until a drop of the mixture 
on blue litmus gives a slightly red circle. If the solution 
be too acid, a drop or two of caustic solution will render 
it neutral. The precipitate is thrown on a filter, and 
washed with a saturated solution of zinc urate. This 
solution is made by adding a little zinc sulphate to 
distilled water, and then adding urate of soda until 



CLINICAL SIGNIFICANCE OF URINE. 127 

a permanent precipitate remains; this precipitate is 
allowed t9 subside, and the solution is used for washing 
until all urea and ammonia are removed. The drained 
precipitate is folded in the filter and placed with 50 cubic 
centimetres of hypobromite of sodium of full strength in 
an urea estimation apparatus, and agitated carefully. 
The gas evolved will be an indication of the amount of 
uric acid present in 100 cubic centimetres of the urine, 
inasmuch as 8 cubic centimetres of nitrogen gas at 60° 
F., and 30 in barometer are evolved from 10 cubic centi- 
metres of a solution of sodium urate, (containing 648 
grammes of uric acid in 100 cubic centimetres) plus 90 
cubic centimetres of water. The reaction is complete at 
the end of half an hour without the application of heat. 
The practitioner will guard against confusion in the 
use of the terms "uric acid" and "urates" by remember- 
iug that urates are a combination of uric acid with 
sodium, etc., and it is customary to estimate the amount 
of this uric acid, which is in combination, and to speak 
often of urine containing so much "uric acid," meaning 
simply the amount of uric acid in combination with the 
sodium, etc., forming urates. Uncombined uric acid is 
normally present only in very small amount ; when plen- 
teous it forms a sediment. 



COLORING MATTERS. 

Determination of Urinary Coloring Matter. — Vogel's 
table of colors gives results sufficiently accurate for clin- 
ical purposes ; filter the urine, pour it into a glass jar of 
not less than 4 or 5 inches diameter and observe what 
color in Vogel's scale it nearest corresponds to. (Books 
of colored papers representing the colors of Vogel's scale 



128 



CLINICAL SIGNIFICANCE OF URINE. 



can be had of dealers in chemical apparatus and of many 
surgical instrument makers.) 

After having ascertained the color of the urine consult 

the following table : 



I 1 


11 


111 


"\ 


V 


VI 


VII 


VIII 


IX 




T *> 


4 

2 


16 


-X2 


6 4 


128 


256 


Pale Yellow = I 


1 


I 


4 

z 


8 


t6 


3 2 


64 


128 


Light " =11 




T 


4 


8 


16 


3 2 


64 


Yellow = HI 






Ik 


I 


A 


8 


16 


3 2 


R'ddish" = IV 








I 


2 4 

I 2 


8 
4 


16 
8 


Yell'ish Red = V 
Red =VI 














1 


2 
I 


4 
2 


Brownish " =VII 
R'd'shBr'wn=VIII 
















1 


Brownish Bl'k == IX 

.. 



Form a proportion as follows : 

1000 : the number corresponding to the color of the 
urine : : the quantity for 24 hours : x. 

If the urine is yellow look under III and we find the 
first figure to be 4 ; therefore 1000 : 4 : : quantity for 
24 hours : X. Suppose in 24 hours 1800 cubic centi- 
metres of urine were passed, then 1000 : 4:: 1800 : x, 
or x = 7.2 parts coloring matter in 1800 cubic centi- 
metres yellow urine. 



CREATININ AND HIPPTJRIC ACID. 

The urine of twenty-four hours normally contains 5 or 
10 grains of creatinin ; it is of no clinical significance. 

Hippuric acid is increased by the eating of much fruit, 
especially prunes, mulberries and bilberries, and by the 
ingestion of the balsams of Peru and tolu and benzoic 
acid. The microscopical appearance of hippuric acid 
crystals may lead one to possible confusion with those of 
triple phosphate. Hippuric acid, however, rarely, if eyer, 



CLINICAL SIGNIFICANCE OF URINE. 129 

deposits itself in the urine spontaneously ; a drop of hydro- 
chloric acid has no effect on its crystals, but dissolves the 
triple phosphates. The normal amount of hippuric acid 
is 0.5 to 1.0 grammes (7 to 15 grains) in twenty-four 
hours. 



ABNORMAL CONSTITUENTS OF URINE. 

Albumin. — The term "abnormal constituent/' with 
reference to albumin, is here used notwithstanding the 
observations of many who have found a small amount of 
albumin in the urine of healthy individuals. For instance, 
Senator, of Berlin, examining the urine of himself and 
three colleagues, found traces of albumin occurring every 
now and then at different times in the day. Frerichs, J. 
Vogel, Ultzmann, De Mussy, Leube, Gull, Edlefson, 
Marcacci, Munn, Bull, Fuerbringer, and others, have 
recorded cases of a similar nature. The routine practi- 
tioner is not apt to be greatly puzzled by finding albumin 
for which he can not account, since the so-called " normal 
albumin" occurs in very small amount and is not likely 
to be noticed by one making a hurried test and having 
little experience in chemical manipulations. Any one 
interested in the subject will find its literature given by 
Dr. Ellis, of Harvard Medical College, in the Boston Med- 
ical and Surgical Journal, as well as an interesting paper 
and discussion in the report of the stated meeting of the 
New York Academy of Medicine for Dec. 15, 1881, and a 
long chapter in Senator's new monograph, Die Albu- 
minuric. 

Transitory albuminuria has been noticed in the urine 
after injury to the skull. (Peabody.) After the drink - 
9? 



130 CLINICAL SIGNIFICANCE OF URINE. 

ing of a pint of milk. (Smith.) After external appli- 
cations of iodine. (Bouchut.) After inhalations of tur 
pen tine. (Emerson.) After persistent albuminous diet. 
After excessive smoking of cigarettes. (Bradley.) After 
poisoning by oxalic acid. (Silk.) After inunction with 
Goa powder ointment. (Israel.) After use of iodoform 
dressings. (Zeissl.)* 

Diseases, etc., not Bright's, in which Albumin may be 
Found in the Urine. 

I. Diseases in which notable diminution of oxidation 
follows a difficult respiration : croup, laryngeal diphthe- 
ria, ascites, emphysema with much dyspnoea, pulmonary 
phthisis (especially if complicated with pneumonia and 
there is great difficulty of respiration), pregnancy and 
the puerperal state. 

II. Cyanosis : heart troubles, where there is partial 
asphyxia. 

III. Eclampsia. 

IV. Cholera. 

V. Idiopathic or traumatic lesion of nerve centres, 
with lowering of temperature and notable diminution of 
combustion. 

VI. Diabetes. 

VII. Curvature of the spine. 

VIII. Natural or artificial suppression of cutaneous 
perspiration : measles, scarlet fever, small-pox ; also after 
intense cooling of surface of body, as in a cold bath. 

IX. Septicaemia, hospital gangrene, phlegmonous ery- 
sipelas, yellow fever, typhoid fever, typhus. 

X. Miliary sweat, jaundice, chlorosis. 
XL Gout, red gravel, rheumatism. 

* According to Kocher, acute nephritis may follow the use of iodo- 
form dressings. 



CLINICAL SIGNIFICANCE OF URINE. 131 

XII. Cachexies : syphilis, cancer, malaria, scrofula. 

XIII. Febrile and inflammatory diseases in general : 
zymotic diseases, peritonitis, traumatic fever, meningitis, 
etc. ; inflammatory affections of the skin : anthrax, fur- 
uncle, erysipelas, burns. 

XIV. Diseases due to hydraemic condition of blood 
with atony of tissues : purpura, scurvy, pyaemia, etc. 

XV. Nervous prostration from grief. 

XVI. Impediments to the circulation : abdominal 
tumors, cirrhosis, etc. 

XVII. Temporarily, after excretion of irritating sub- 
stances, as balsam copaiva, turpentine, cubebs ; of con- 
centrated, highly acid urine ; of oxalate of lime and sharp 
crystals of uric acid. 

XVIII. Temporarily, after various vascular contrac- 
tions: convulsions, epileptic and intermittent fever par- 
oxysms. 

Drugs causing the Appearance of Albumin in the Urine: 

I. Anaesthetics, among them chloral hydrate. 

II. Many emetics and cathartics, especially drastic 
cathartics. 

III. Potassium nitrate. 

IV. Coffee (sometimes). 

V. Fuchsin, especially arsenical fuchsin. 

VI. Various metallic salts : the mercurials, soluble 
compounds of antimony and lead, some salts of silver, 
and of cadmium, uranium nitrate, salts of copper, the 
arseuicals, chloride of gold and platinum. 

VII. Poisoning* from arsenuretted hydrogen, carbon 
protoxide and dioxide, phosphorus, iodine, potassium 
iodide, carbolic acid (sometimes.) 

* Prof. Wood reports albumin and casts in urine of patient who had 
been taking heavy doses of salicylic acid. (See page 137.) 



13 2 CLINICAL SIGNIFICANCE OF URINE. 

The injection of water into the veins may produce 

albumin in the urine. 

Xmin is more often found in the urine of those who 
liifnTigh altitudes than in that of those who live » 

10 Xf^ing points in regard to the appearance of 
alhumin in the urine are of particular importance : 

(Tin diphtheria, albumin in the urine appears early 
in Ihe disease, an occurrence which is deemed of Agnos- 
tic significance. . pre <mant 

(ii ) If albumin occur m the urme 01 a preg 
woman look for casts (with the microscope,) and other 
TiTntes of renal disease. Since puerperal eclampsy 
often accompanied by parenchymatous nep tat* 1. e^ 
Animation of the substances of ^ kld ^" * 
presence of albumin alone, without other s lg ns of ktdney 
rHspase is not necessarily alarming. 

% T) If the urine contain leucorrhceal discharge or 
Jrmatic fluid, albumin may be found due to the* 
xfresence and no kidney disease is necessarily present. 
P X) A pale, dilute urine abundantly albummous is 
Jr Vindicative of Bright's disease than a dense, high, 
Colored urine with less albumin, which 1a more apt to be 
S£L of pyrexia or some impediment to the cncula- 

ti0 i:l uX ««* be found in the urine, see next 

Par r a fi r s a e P Albuminuria-When the urine contains pus or 
Jod a not large amount of albumin is likewise found ; 
th t he albumin of the blood or of the pus smce both 
S th se substances contain it ; to get an idea of abou 
«h albumin belongs to pus, add to nermann 
some pus from a suppurating wound and after allowmg 



CLINICAL SIGNIFICANCE OF URINE. 133 

the sediment to form, apply the usual albumin test. (See 
Part I.) 

This condition is termed false albuminuria and is found 
in diseases of the excretory passages and bladder, as, 

(i.) Cystitis. 

(ii.) Xew growths in the bladder. 

(iii.) Stone in the bladder. 

(iv.) Prostatis and hypertrophy of prostate. 

Again, there are diseases in which besides pus and 
blood, more albumin occurs in the urine than the pus and 
blood will account for ; these are diseases of the kidney- 
pelvis — pyelitis in its various forms; haemorrhage from 
the kidney may be accompanied by more albumin than the 
blood will account for. 

Bright's Disease. — Albumin is found in the urine of 
the various Bright's diseases, accompanied generally by 
abundant casts, renal epithelium, and fatty cells, by the 
presence of which they can be differentiated from simple 
hyperaemia, febrile hyperemia, renal stasis proper, and 
false albuminuria. 

Vulpian has noticed that in Bright's diseases the 
albuminoids in the saliva are augmented. 

In Bright's disease the albumin in the blood is dimin- 
ished. 

Summary. — Sir Henry Thompson makes the following 
observation in regard to albumin in the urine: "When- 
ever clear urine of acid reaction, free from blood, con- 
tains a notable amount of albumin, such albumin is 
usually of renal origin. 

Professor Wood on Quantity of Urine in Bright's Disease: 

An important aid in the diagnosis of the Bright's dis- 
eases, is knowledge of the daily amount of urine passed. 
"In only an exceedingly small percentage of the cases in 



134 CLINICAL SIGNIFICANCE OF URINE. 

which I examine the urine I am able to learn, approxi- 
mately, how much the patient is passing," says Prof. E. 
S.Wood, of the Harvard Medical School; "in private 
practice measurement of the urine, in cases of known or 
suspected renal disease or complication, is the rare ex- 
ception. * * * 

"It is no hardship to require actual measurement of the 
urine in case of patients who are not confined to the 
house, since they can be provided with a wide mouthed 
bottle fitted with a tight stopper and sufficiently large to 
contain the amount passed at a single micturition. This 
bottle can be graduated into twenty-five or fifty cubic 
centimetre spaces or into fluid ounces, by a file mark on 
the glass or by marks on a strip of paper pasted on the 
outside. This may, if necessary, be carried in the pocket 
and the amounts passed at each micturition be noted; 
* * * in acute parenchymatous nephritis the amount 
is at first much diminished, and then gradually increases 
with the diminution of the inflammation up to the nor- 
mal amount ; with convalescence it exceeds the normal 
considerably ; and finally, in those cases which terminate 
in recovery with complete restoration of the kidney to a 
healthy condition, it falls again to the normal. 

"In chronic parenchymatous nephritis the amount of 
urine is always below normal, any increase above normal 
rare or temporary. With the increase of the disease 
accompanied by increasing dropsy, the amount is very 
small and the urine concentrated; but when the piogres- 
sion is not active the amount is but little below normal. 
"In both interstitial nephritis and amyloid degenera- 
tion the amount of urine is largely increased, even to 
three and four times the normal amount except during a 
short time previous to death when the quantity may be 



CLINICAL SIGNIFICANCE OF URINE. 135 

less than normal. In complicated cases, which are far 
more common than uncomplicated ones, the amount of 
urine varies according to the nature and extent of the 
complicating affection. * * * The result of the ad- 
mixture of chronic or acute parenchymatous nephritis 
with either the interstitial or amyloid degeneration, is to 
diminish the amount of urine and the amount of this 
diminution is dependent upon the extent of the paren- 
chymatous complication * * * 

"If a parenchymatous affection exists as a complica- 
tion of either an interstitial nephritis or an amyloid 
degeneration, it is almost sure to be detected by the 
increased amount of albumin and the character of the 
sediment; the measurement of the amount of urine is 
often in these cases of especial importance in making a 
diagnosis of such complications. If, for example, we 
have a specimen of urine with hyaline, granular, and 
fatty renal epithelium in the sediment, and at the same 
time the urine contains a considerable amount of albu- 
min, it is impossible for us to say whether it is a case of 
pure chronic parenchymatous nephritis, or one of the 
other forms of Bright's disease in which the parenchy- 
matous affection is merely a complication ; but if we 
knew that the daily amount of urine averaged between 
2000 and 3000 cubic centimetres, we might be reasonably 
sure that the parenchymatous disease was not the princi- 
pal one but only a complication. If the parenchymatous 
affection is the principal one the amount of urine will be 
diminished, in which case it is impossible without the 
history of the case to determine the existence of any of 
the other forms of organic renal diseases. 

"It is well known that Bright's disease is diagnosticated 
chiefly by the detection of albumin in the urine and renal 




136 CLINICAL SIGNIFICANCE OF URINE. 

casts in the urinary sediment, and I frequently meet 
physicians at the present time who pronounce the exist- 
ence of serious organic renal disease from these character- 
istics alone, which may occur without serious disease of 
the kidney. Daily measurement of the urine in these 
cases is of very great assistance. In hypersamia of the 
kidneys, for instance, due to disease or abnormal condi- 
tion of some other organ we frequently find both albu- 
min and casts, and a knowledge of the amount of urine 
may prevent an error in diagnosis and prognosis. In 
passive hyperemia of the kidneys, due to cardiac or other 
disease we find in the urine, so far as the kidneys are con- 
cerned, only hyaline and finely granular casts and a trace 
of albumin — conditions which are only found in the inter- 
stitial and amyloid forms of Bright's disease; but the 
average daily amount of urine in passive hyperemia is 
diminished, while in the above-mentioned organic diseases 
it is much increased. 

" In active hypersemia of the kidneys, due to the elim- 
ination of some virus or drug, the amount of urine is 
usually diminished, owing to the febrile complication, 
and in addition to the sediment mentioned above in cases 
of passive hyperemia, we find free blood and renal epi- 
thelium and usually an occasional blood and epithelial 
cast ; albumin is present only in mere traces. 

"These characteristics of the urine and sediment are 
the same as those of acute nephritis, but in the propor- 
tion which they occur in the stage of convalescence, when 
in acute nephritis the amount of urine is increased, and 
often much increased, while in this condition of hyper- 
emia it is almost always diminished. * * 

"I have known a diagnosis of chronic Bright's disease 
to be made in a case of cerebral disease, in which the 




CLINICAL SIGNIFICANCE OF UftlNE. 137 

urine contained a trace of albumin and the sediment 
hyaline casts with blood and renal epithelium ; yet the 
amount of urine was about normal and more than fifty 
grammes of urea were being eliminated — a condition of 
things which should lead one to give at least a doubtful 
diagnosis, so far as the kidneys are concerned, and to 
wait for* time to show whether a temporary or a perma- 
nent affection existed. In this case the casts and albumin 
have entirely disappeared. 

"In typhoid, rheumatic, and other fevers we often see 
in the urine a few hyaline casts and a trace of albumin, 
with a diminished amount of urine. In these cases 
parenchymatous disease of the kidneys can be eliminated 
by the character of the sediment and the proportion of 
albumin, and the same composition of the sediment can 
only be eliminated with absolute certainty by waiting until 
the fever has subsided and examining again, although 
a normal or increased amount of solids, with the dimin- 
ished amount of urine, points very decidedly to the 
absence of any serious renal disease. 

"In many cases of acnte rheumatism, especially after 
the exhibition of salicylic acid and the salicylates I have 
found a trace of albumin in the urine, and hyaline and 
finely granular casts with blood and renal epithelium in 
the sediment. * * * I have seen some of these cases 
in which the casts and albumin entirely disappeared, but 
in which the diagnosis of chronic Bright's disease had 
been made j an error which would not have occurred had 
due regard been paid to the amount of work which the 
kidneys were capable of doing and to the average daily 
amount of the urine." 

In rare cases of Bright's disease albumin may disappear 




138 CLINICAL SIGNIFICANCE OF UBINE. 

from the urine in the coursa of the disease ; it is often 
the case that it diminishes in amount. 

Hints for Diagnosis of Bright's Disease. — Urine perma- 
nently albuminous, when neither pyrexia nor thoracic 
disease, nor other condition exists whioh may account for 
the presence of albumin, is apt to indicate organic disease 
of the kidney. If an abundant deposit containing casts 
and much renal epithelium or numerous casts and cells in 
a state of fatty degeneration be also found, the proof is 
almost positive, if due regard to the quantity of urine and 
to the amount of urea excreted, be paid. 

The lower the specific gravity in kidney troubles the 
more serious the case. 

Sugar. — The sugar which is found in urine is not cane 
sugar, but more closely resembles grape sugar or glucose, 
hence the term glycosuria. Glycosuria (sugar in the 
urine) is a very different thing from diabetes mellitus ; 
sugar in the urine may often be found when the patient 
has not diabetes mellitus, but the latter malady seldom 
exists without sugar in the urine. Sugar may appear in 
the urine as a result of the following diet : immoderate 
use of starchy and saccharine food ; generally the amount 
of sugar in such cases is very small but occasionally large 
amounts have teen known to appear. 
Diseases not Diabetes Mellitus in which Sugar may Appear 
Temporarily in the Urine: 

I. Cerebral disturbances, or those of the nervous,system 
in general, especially of the medulla. 

II. Disturbance of various bodily processes: diminu- 
tion of respiration and absorption of oxygen ; excessive 
production of sugar by the liver ; diminution of the alka- 
lies in the blood. 

III. Pregnancy and child- bed. 



CLINICAL SIGNIFICANCE OF URINE. 139 

IV. Plethora, especially of women at menopause. 

V. Old age. 

VI. Skin diseases : suppurative stage small-pox, suppu- 
rations generally, eczema of the genitals. 

VII. Tetanus rheuinaticus and intermittent fever 

(temporarily). 

VIII. Various disorders: hepatic or gastric troubles, 
typhus, malarial fever (6 to 8 grammes to the 1000 cubic 
centimetres of urine at most), pneumonia, acute febrile 

processes. 

IX. Convalescence from cholera, rougeola, and erysip- 
elas, (amount small). 

X. In various diatheses : phthisis, syphilis. 

XL Rheumatic gout and rheumatism ; if the gout be- 
comes atonic danger of diabetes mellitus. 

XII. Gangrenous and ulcerative processes: uterine 

ulcers, severe burns. 

XIII. After paroxysms of whooping cough, asthma or 

epilepsy. 

XIV. After miscellaneous mishaps: blow in the epi- 
gastrium, disordered digestion, intense grief, sudden men- 
tal shock, exposure to cold, hereditary influence. 
Agents which may cause Sugar to Appear in the Urine : 

I. Oil of turpentine. 

II. Chloral hydrate and various anaesthetics. 

III. Nitro-benzol. 

IV. Carbonic oxide gas (poisoning from). 

V. Amyl nitrite. 

Diabetes Mellitus. — In diabetes mellitus large amounts 
of sugar may be persistently present in the urine ; the flow 
of urine is enormously increased, there is emaciation, great 
thirst, etc., in typical cases. If the urine of a patient per- 
sistently contain sugar, while at the same time other well- 



140 CLINICAL SIGNIFICANCE OF UKINE. 

known symptoms are present, there is reason to fear 
diabetes mellitus. In rare cases sugar may be absent. 

Diet which Increases Sugar in the TJaine (to be Avoided 
by Diabetics) : 

All substances containing sugar: sugar, sirups, pre- 
serves, sweet wines, champagne, beer, cider ; fruits con- 
taining sugar, as raisins, figs, bananas, pine-apples, mel- 
ons ; farinaceous foods, as bread, pastry, dumplings, rice, 
macaroni, vermicelli, tapioca, potatoes, carrots, lentils, 
kidney beans, etc. (Hardy.) 

Diet which does not Increase Sugar in the Urine (to be 
Used by Diabetics) : 

Boullion, cabbage soup, bisque soup, game, fish, poul- 
try, string beans, spinach, asparagus, tea and coffee with 
glycerine instead of sugar ; slightly acid fruits, peaches, 
cherries, currents; Bordeaux and Burgundy wines, red 
wines; alkaline mineral waters (in early stages of the 
disease). 

The amount of urine in diabetes mellitus may vary 
from eight to fifteen pints, occasionally over thrity pints ; 
the specific gravity is generally very high, 1030 to 1052, 
generally about 1040 ; the color is apt to be pale, the odor 
faintly agreeable like that of new mown hay; the urine 
froths readily when poured from one glass to another. 

The urine is itself generally clear and its taste sweet. 

When the excretion is considerable in amount, exceed- 
ing four or five pints, the color may be described as a 
pale straw tint and the aspect of the urine is noticeably 
bright, but where the quantity passed is less than this, 
the ordinary color obtains ; the average quantity of sugar 
passed daily ranges from 15 to 25 ounces, although more 
than two pounds have been observed. 

If the quantity of sugar is large a sweetish, whey-like 



CLINICAL SIGNIFICANCE OF URINE. 141 

odor is noticed ; sediments are rarely observed in diabetic 
urine. (See Fungi.) 

Freshly passed diabetic urine is usually neutral or alka- 
line but soon becomes strongly acid owing to fermenta- 
tion ; if a bottle be filled with diabetic urine, corked and 
set in a warm place, so much carbonic gas may be gener- 
ated as to flow out the cork. Cloths soaked in diabetic 
urine, when dried, become sticky and look as if they were 
coated with honey. 

Albumin and Sugar Together. — Th. Frerichs finds albu- 
min occurring together with sugar under three conditions : 

I. Glycosuria. 

II. Diabetes mellitus. 

III. Chyluria. 

Albuminuria is a frequent complication of glycosuria, 
according to Frerichs, occurring in fifty per cent of such 

cases. 

Glycosuria may occur in the course of acute and 
chronic cerebral affections, and with it Frerichs found 
albuminuria in (i.) aneurism of brain rupturing into 
ventricles, (ii.) extensive apoplectic effusions, (hi.) puru- 
lent general meningitis, (iv.) chronic tubercular basilar 

meningitis. 

In acute cases the prognosis is occasionally favorable, 
most so in meningitis, but in chronic cases unfavorable 
as a rule. Nephritis rarely complicates diabetes mellitus 

in fiye per cent only of the cases observed by Frerichs. 

All cases of diabetes mellitus complicated with phthisis 
and albuminuria terminated fatally; others where the 
albuminuria depended on cystitis and subsequent nephritis 
ended in recovery. In chlyuria (chyle in the urine) 
albumin, sugar, and fat may be found in the urine. 
Bile. The presence of bile coloring matter in the urine 



142 CLINICAL SIGNIFICANCE OF URINE. 

is of slight clinical importance and the occurrence of bile 
acids very rare. In icterus and in phosphorus poisoning, 
also after severe burns, bile may be detected in the urine, 
but the demonstration of its presence there is not the 
only means of diagnosing these conditions, as may readily 
be imagined. Urine containing bile pigments is richly 
colored, deep brown, reddish brown, greenish brown, daTk 
green or grass green; it foams strongly on being shaken 
and colors unsized paper yellow or greenish. 



DEPOSITS. 

The terms urinary sediment, urinary deposit, are used 
to describe the various substances precipitated from urine 
(in which they are held in solution or suspension) when 
this fluid is at rest for a longer or a shorter time. 

Normal urine on standing shows a light, scarcely visi- 
ible cloud ; when, however, a plainly visible turbidity is 
seen which, as the urine stands, shows a tendency to form 
a sediment, it is necessary to examine the same with a 
view to ascertaining the constituents of the deposit and 
their clinical significance. 

Beale divides deposits into three classes : 

I. Light, flocculent, transparent, voluminous deposits : 
mucus and epithelium, spermatozoa, vibrions, fungi, casts. 

II. Dense, opaque, bulky : urates, pus, phosphates. 

III. Granular or crystalline, small bulk, sinking to bot- 
tom or deposited on sides of the urine glasses : uric acid, 
calcium oxalate, triple phosphate, cystin, lime carbonate, 
blood corpuscles. 

N. B. — A very thick, glairy, gelatinous deposit is pus 
altered by the action of ammonium carbonate. 

The distinction between the first two classes is easily 



CLINICAL SIGNIFICANCE OF UKINE. 143 

made, inasmuch as urates, pus, and phosphates, Class II, 
soon sink to the bottom of the urine glass, leaving a 
stratum of clear urine above them, whereas the constitu- 
ents of Class I. are so light as to require a long time for 
settling, and even then, the supernatant urine will not be 
as clear as in case the deposit were of Class I. The essen- 
tial characteristic of deposits of Class III. is their very 
small bulk compared with that of the others. 

By noticing to which of these three classes a sediment 
seems to belong, the physician may gain considerable 
time in his chemical or microscopical examination of the 
same. 

The order in which the constituents of sediments will 
be described is as follows : 

Phosphates, 
Urates, 
Uric acid, 
Calcium oxalate, 
Calcium carbonate, 
Pats. 



x 



Unorganized sediments. 



Mucus, 

Epithelium, 

Tube casts, 

Blood, 

Pus, 

Spermatozoa, 

Pungi, 

Entozoa. 



-\ 



y 



Organized sediments. 



Phosphatic Deposits. — A deposit of phosphates in the 
urine indicates an alkaline or neutral condition of the 
secretion which if occurring after a meal or after partak- 
ing largely of fruit, carbonates, citrates, or acetates of the 
alkalies is of no clinical importance. If, however, a 
deposit be seen daily for some little time with an alkaline 
reaction of the urine, examine with the microscope : if 



144 CLINICAL SIGNIFICANCE OF URINE. 

the deposit be (i.) amorphous — i. e., containing no crys- 
tals — nervous exhaustion as from severe study or loss of 
sleep may be indicated, provided copious draughts of min- 
eral waters had not been taken; if the deposit be (ii.) 
crystalline and consist of (a) calcium phosphate, it may be 
due merely to diet rich in lime, or else to disease of the 
spinal cord and chronic vesical affections ; if the deposit 
be crystalline and consist of (V) ammonium magnesium 
phosphate it is of considerable clinical significance, if 
occurring in freshly passed urine. 

Ammonium Magnesium Phosphate. — When the urine 
is alkaline from the presence of volatile alkali, i. e., am- 
monia formed from decomposition of urea, we have in 
addition to the deposit of phosphate of lime, crystals of 
ammonium magnesium phosphate — "triple phosphate" 
as it is sometimes called. The presence, therefore, of 
crystals of triple phosphate when persistent in the urine 
is indicative of local disease of the urinary organs and not 
of constitutional disturbance. 

Diseases in which Triple Phosphate is Deposited in the 
"Urine : 

I. Retention of urine (after). 

II. Paralysis of the bladder. 

III. Formation of calculus. 

1ST. B. A deposit of triple phosphate in stale urine, o 

that received into dirty chamber vessels is of no clinica 
significance as regards the above three conditions. More- 
over, a dirty catheter may be responsible for fermentation 
of the urea in the urine while in the bladder and triple 
phosphate may appear. In order, therefore, to form a 
correct idea of the clinical significance of this substance 
it must be discovered in urine freshly passed into a clean 
vessel. 



CUBICAL BICHXnCAjrCS OF CBIXE. 14J 

Urate Deposits— Pa rients often complain of a "brick- 
dmrt sediment in the urine, and this lurid deposit causes 
r d mnch uneasiness, suggesting by a logical (?) pro- 
cess the presence of the terrible destroyer "Brighfs dis- 
ease ": practitioners having "the i m of a serpent" 
should thoroughly appreciate the fact that occasional 
"brick-dust" sediments are u "harmless as a dove"; 
they may be due to one or more of the following : 

Causes of an Occasional Brick-Dnst (Amorphous Urate. 
Sediment in the Urine : ' 

I. Over-eating or drinking ; also prolonged abstinen 
from food and drink. 

II. (rreat exertion, revelry or excitement. 

III. Hard study. • 

IV. Fright. 

V. Change in the manner of living; getting out of a 
warm bed into a cold room. 

VI. Profuse perspiration with diminution of amour, 
of urine. 

± frequent or percent "brick-awst" sediment should 
on the contrary receive the most careful attention of thr 
busy practitioner. 

Diseases in which Urates are Deposited in the Urine: 

I. Febrile disturbances: colds," fevers, inflammatorv 
diseases; here we may include pulmonary emphysema. 
ordinary fevers, capillary bronchitis, diphtheria, dysentery 
influenza, intermittens (febrile stage), nephritis; scarlet 
fever (at eruption), tetanus, acute polyarthritic rheuma- 
: = :: ;fter severe burns, etc 

Diseases in which Urates may be Steadily Deposited in 
the Urine: 

I. Xon-inflammatory disorders: (i) Chronic affections 

tio 



14 6 CLINICAL S10NIF1CAHCE OF DKIUE. 

heart liver, spleen : (ii.) Digestive disturbances in cliil- 



""he presence of nrio acid and of mates in the urine 
ta form or deposits is one of the most constant sign, of 

'Tn^rdTrJllt.rteaofpathologic.ini- 
L .lUoccnr in febrile states, or febrile exacerbations 

5SSK : in -oh — «. " •££"£ 

* 11t ?t»p of strongly acid reaction , tne coioi 

leYiart q mount 01 Urine, 01 btiuii^ij t* 

ZTona. ofga c dexangenrent ; the paler the color, 
T e 12 the condition of cotaneons tactions, usually, 
"the region o, the Mnevs, fatigne or oongesrion 

ot these organs, doe to .ooal ««£*J ^ 

i. ru;~v> if npourriiisr m tlie oiaaaer Ltuiu, v^ 
deposits which if ooonm g ^ ^^ 

toward forma ion o atone In inflammatorv 

are steal* deposited and no teome 
.cmotoms are present, incipient gravel or calculus is men 
S; nenatl, disease of some abdominal organ is apt, 

*Z7^7lTl have been speaking thns far 
are the anZhona or non-ervstaUine, but «--* J» 
gout and in seme febrile •£%£%£%£, 

Wh6U t ' be dTTre^e ' intruder, the^—W 
gravity, and long retameu sabs tance 

rilcCvisitor, ,ritating, as it *.£££*£ 
brane of the bladder and urethra with •* bmta ^ 
td> • it has been known to occlude the urethra w 
Spited masses of its deposit and the freipienc, of ve,- 



CLINICAL SIGNIFICANCE OP UEINE. 147 

cal calculi in children may possibly be due to the occur 
reuce of this deposit." 

(In examining urate deposits microscopically always 
procure fresh urine, not over a day old, since* various 
forms of crystalline urates may be deposited at the end of 

alkalineT entati0U "* * ** ******* of a « d during 

Ordinary amorphous urates appear as irregular particle, 
of granular powder: to tell them from amorphous cal- 
cium phosphate, add acetic acid-tbe phosphate is dis- 
solved but the urates gradually turn into uric acid. 

Free Uric Acid as a Sediment-Uric acid, in a free 
state, i e., uncombined with sodium, potassium, etc.. is 
frequently found as a deposit in the urine, normally so 
token the urine has entered the condition known as acid fer- 
mentation, i. e., when twelve to twenty hour, old 

Deposits of uric acid depend upon chance, m the 
urinary secretion. (Ralfe.) 

Deposits of Uric Acid in the freshly-passed Urine- 
I. Due 10 absolute increase in the acidity of urine- (a) 
Occasionally in winter, action of skin checked, acidity of 
the urme increased and uric acid deposited : (5) eczema 
psoriasis and other cutaneous disorders; { c) all forms of 
dyspeps.a associated with irregular secretion of gastric 
juice. ("Acid dyspepsia."— Ralfe.) 

II. Due to relative increase in the acidity of the urine ■ 

(a) Summer weather, when perspiration being increased' 
amount of urme is diminished and uric acid deposed : 

(b) for same reason in febrile and inflammatory disorders 
especially m rheumatic fever and in diarrhoea; (,) alter- 
natmg with appearance of sugar in the urine-sugar dis 
appearing, uric acid is deposited, and vice versa; (rf) in 



148 CLIJS T ICAL SIGNIFICANCE OF URINE. 

urine of ill-nourished or strumous children caused by 
deficiency of alkaline phosphates. 

Hints for Diagnosis. — If the deposit of uric acid occur 
before the urine cools or immediately after it, the formation 
of gravel or stone is to be dreaded. 

If the deposit occur three or four hours after the 
urine is passed, gravel and stone are not so much to be 
dreaded. 

If the deposit occur twelve to twenty hours after the 
urine is voided, when acid fermentation has set in, it is 
perfectly normal. 

According to Anstie, nothing is more common in neu- 
rotic patients, without rheumatism, than a fluctuation 
between lithiasis and oxaluria from defective secondary 
assimilation of food. 

In gout, uric acid and the urates are held back, but 
after the paroxysm, are often voided in great abundance. 

Calcium Oxalate. — Fuerbringer shows that oxalic acid 
in small quantities is a normal constituent of urine. 
Oxalate of lime (lime and oxalic acid combined) deposits, 
on the contrary, are, if persistent, of pathological signifi- 
cance. Occasional deposits of lime oxalate may be due to 
physiological causes : 

I. Derived directly from food by the ingestion of sub- 
stances containing oxalate of lime, as cauliflower, bananas, 
carrots, apples, asparagus, turnips, onions, rhubarb, garlic, 
tomatoes, sorrel, gooseberries, water cresses, parsnips, etc. 

Persons in weak health eating heartily of these vege- 
tables will often have an attack of indigestion in conse- 
quence, and lime oxalate crystals will temporarily appear 
in the urine. 

II. Derived indirectly from food, incomplete oxidation 
of sugars, starches, and fats ingested. 



CLINICAL SIGNIFICANCE OF URINE. 149 

Sugar, starch and fat are, it is known, converted finally 
into carbonic acid and water in * the system ; any check 
to this process of conversion will lead to the appearance 
# of oxalate of lime crystals in the urine, which will in due 
time disappear without any apparent alteration of health. 
III. Certain drugs, as gentian, rhubarb, squill, vale- 
rian, and many others ; alkaline waters, carbonated drinks, 
fermented liquors, sparkling wines, may be responsible, if 
taken, for the appearance of lime oxalate crystals in the 
urine. 

Diseases in which Oxalate of Lime may be Deposited in 
the Urine: 

I. Febrile disorders. 

II. Pulmonary and cardiac affections in which respira- 
tion is impeded. 

III. Disorders of the hepatic functions. 

IV. Depressed conditions of the nervous system. 

In these disorders the urine is generally of a deep orange 
color, of high average specific gravity, containing excess 
of urea and phosphoric acid and generally turbid with 
mucus and urates ; the deposits of oxalate of lime are 
not always persistent, often disappearing for a few days 
to return as;ain iu great abundance. 

Besides the disorders just mentioned, oxalate of lime 
crystals may be found in the urine of (i.) spermatorrhoea 
and (ii.) dyspepsia (certain forms). 

It is to the latter of these two diseases that the term 
"oxaluria' properly belongs, while to the derangements 
associated with uric acid deposits the term "lithseniia' is 
given. 

According to Ralfe the victims of oxaluria are most 
frequently country patients, especially those residing in 
damp and marshy districts or on cold, ill-drained clay 



150 CLINICAL SIGNIFICANCE OF URINE. 

soils ; situations, in fact, in which catarrhal affections of 
the intestinal canal are likely to be engendered. The 
urine is usually of a pale greenish color, the quantity in ^ 
twenty-four hours normal, likewise the specific gravity. • 
Its chief characteristic is the deposit of crystals of oxalate 
of lime which are found most abundantly in the morning 
urine passed on first rising. Owing to the presence of 
these crystals causing irritation of the mucous membrane 
of the bladder, micturition is frequent and urgent, though 
the quantity of urine passed is not large. 

Patients suffering from oxaluria experience considerable 
mental depression and various anomalous symptoms indic- 
ative of nervous disturbance, as burning sensation across 
the loins, tightness and dragging around the abdomen, 
shooting and burning pains in the lower limbs, twitching 
of certain groups of muscles, with often a feeling of 
numbness, deadness and coldness. Treatment directed 
to the relief of the dyspeptic condition may result in im- 
provement, enabling the physician to differentiate this 
disorder from early stages of locomotor ataxy. 

Summary. — Oxalate of lime crystals may be found in 
the urine as follows : 

I. After ingestion of certain articles of diet; of certain 

drugs. 

II. After incomplete oxidation of sugar, starch and 
fat. Regulation of diet, change of air, etc., improve this 

condition. 

III. From increased tissue metabolism as shown by in- 
crease of urea and phosphoric acid, found in many dis- 
orders of liver, heart and lungs— high-colored urine. 

IV. Spermatorrhoea. 

V. Persistent deposits of oxalate of lime in those cases 



CLINICAL SIGNIFICANCE OF UBINE. 151 

of dyspepsia to which the term "oxaluria?" is applicable — 
light-colored urine, 

A constant and large deposit is proof of an abnormal 
condition which renders the formation of oxalate of lime 
("mulberry") calculus possible. 

Remarks of Bouchardat on Urinary Sediments. — Bou- 
chardat calls attention to the fact that persistent depos- 
its (gravel) in the urine, of urates, oxalate of calcium, 
and triple phosphate indicate a superfluous amount of 
these substances in the circulatory apparatus, and deaths 
from embolus, sanguineous or serous effusions into the 
encephalum may take place in such cases ; softening of 
the brain and senile gangrene may be due to capillary 
emboli caused by a deposit of these substances in the 
minute vessels of the brain; ecchymosis of the retina in 
glycosuric amblyopia, accommodative asthenopia, paral- 
vsis of the accommodating muscle, and pareses of accom- 
modation would appear to be due to the same cause. 

Fat. — Eassman divides the affections in which fat occurs 
in the urine into three classes : 

I. Chyluria — parasitic and non-parasitic — where albu- 
min and not infrequently fibrin are found. 

II. Fatty degeneration at some point of the urinary 
apparatus — also where pus from an old abscess finds its 
way into the urinary passages. 

III. Constitutional affections associated with marked 
cachexia or dependent on systemic intoxication, as : 

(i.) Phthisis. 

(ii.) Long-continued suppuration. 

(iii.) Pyaemia. 

(iv.) Yellow fever. 

(v.) Poisoning by phosphorus, by carbonic oxide gas 
{or after poisoning from external use of carbolic acid. — 
Weiss.) 



152 CLINICAL SIGNIFICANCE OF URINE. 

(vi.) Chronic poisoning by turpentine. 

(vii.) Severe injuries to the bones. 

In regard to chyle in the urine very little is known ; its 
presence is not. necessarily unfavorable, except when 
accompanied by coagulated fibrin and renal casts. It 
may occur during the course of epilepsy, erysipelas, dia- 
betes, tuberculosis and other maladies. 0. Bo wen in the 
British Medical Journal reports a case where free oil 
appeared in the urine of a young person who was taking 
cod-liver oil, ceasing when the latter was discontinued. 

Large amounts of oil in the urine may indicate not only 
an abscess opening into the urinary tract, but also may 
show that there is sloughing going on sufficient in extent 
to set free the oil of the fatty tissue; a case presenting 
the above conditions is reported by Dr. Gushing, of Boston. 

Such cases as the above are rare and, in general, unless 
the urine be chylous, no great amount of fat is usually 

found. 

When we see fat drops floating on the surface of a 
specimen of urine, it is well, before making a diagnosis, 
to be sure that unclean, oily or fatty urine glasses, 
chamber vessels, medicine glasses, etc., have not been 
used; if the urine has been drawn off with a catheter 
freshly oiled, oil may be found in the urine. 

Mucus. It will be remembered that a scarcely percep- 
tible mucus "cloud" is normal in urine; when, however, 
this is distinctly visible and readily characterized, a patho- 
logical condition of the urinary passages is indicated. 

Conditions under which Mucus is Present in Abnormal 
Quantity in the Urine : 

I. Irritation of the mucous membrane of the urinary 
passages in general: vesical catarrh (mixed with pus). 



CLINICAL SIGNIFICANCE OF URINE. 153 

II. Irritation of genital mucous membrane (in women). 

III. After gonorrhoea : (long mucus plugs). 

IV. Fevers and acute diseases : pneumonia, pleuritis, 
typhoid fever, meningitis, intermittents, pulmonary and 
intestinal catarrhs, acute delirium, epilepsv. 

Inasmuch as irritation of the urinary tract may develop 
into inflammation, it is of great importance that the 
practitioner be able to tell whether he have mucus present 
in a specimen of urine (irritation) or pus (inflammation) ; 
if he find large quantities of mucus he may be able bv 
proper treatment to prevent the irritation of the mucous 
membrane of the urinary tract from developing into in- 
flammation, and if pus be passed it is important not to 
mistake it for mucus. 

Detection of Mucus: 

I. Examine the deposit, collected in the usual manner, 
with a power of from 200 to 500 diameters ; if leucocytes 
(generic term for white blood corpuscles, pus corpus- 
cles, or mucus corpuscles) be seen, either mucus or pus is 
present ; add a drop of acetic acid and if pale, delicate 
fibrillated or finely punctated bands or threads, sometimes 
tortuous and frequently anastomosed, appear (Fig. 14), 
(precipitated mucin) mucus is present and the corpuscles 
will now show nuclei : pus is not excluded by this exam- 
ination, since the pus corpuscles are of the same form as 
the mucus corpuscles and act the same way with acetic 
acid, namelv, show nuclei. 

II. Mucus, Pus, or both ? 

Thus far, then, it has been decided that mucus is 
present and possibly pus also : next, filter the urine and 
set the filter paper aside to dry. Now test the filtered 
urine for albumin and if any be found, pus is in all prob- 



154 CLINICAL SIGNIFICANCE OF URINE. 

ability present; if none be found mucus is present, as 
determined by the microscope, but pus is not. Some 
times the albumin of pus is so small in amount as to 
escape the notice of the person testing. Mucin is not 
precipitated by mercuric chloride but pyin is. 

Mucus is often present in considerable amount in the 
urine without betraying itself by causing any turbidity ; 
to ascertain whether this be true, add to comparatively 
fresh urine acetic acid which will cause a cloudiness which 
will clear on subsequent addition of hydrochloric acid. 

In II. we directed the filter paper to be dried ; if a 
glistening "varnish" be seen adhering to it after it is 
dried, mucus in abnormal amount is indicated. The use 
of the microscope will confirm the chemical tests for 
mucus; the mucus "cloud" with a power of 450 to 500 
diameters shows besides corpuscles, epithelial cells and 
fatty droplets, a very pale, almost invisible substance ; the 
addition of a drop of acetic acid causes the corpuscle 
nuclei to appear, the epithelia to grow paler, and the pale 
substance to become fibrillary or finely punctated. 

We wish to call attention again to "muco-pus" which 
must not be mistaken for mucus ; when, as in vesical 
catarrh, a glairy deposit is found adhering closely to the 
sides of the vessel, this is not mucus alone but a mixture 
of pus and mucus rendered glairy by the action of carbon- 
ate of ammonium. As has been observed before, this 
substance cannot be dealt with chemically or microscopic- 
ally to any advantage ; the most we can do is to filter the 
urine and test for albumin which if present in small 
quantities indicates the presence of pus ; also observe 
whether triple phosphate crystals are present. 

If we desire to know where mucus comes from, the 






CLINICAL SIGNIFICANCE OF URINE. 155 

character of the epithelial cells always present in it may 
aid us, although any arbitrary classification is impossible. 
These are : 

I. Bound cells from urinary tubules of kidney and 
deeper layers of the mucous membrane of the pelvis of 
of the kidney, and are complete spheres with nuclei. 
. II. Conical and tailed cells from pelvis of the kidney. 
twice as long as broad and broader at one end than at the 
other, with spindle- shaped prolongation at one end or 
both. 

III. Flat cells from vagina or bladder, described as 
irregular, polygonal lamella?, with distinct nuclei situated 
nearly in the centre. 

IV. Epithelial cells of urethra are like those of kidney, 
but albumin is usually present with the kidney cells and 
not with the urethral. 

Epithelium. — A sediment occurring in the urine may 
contain epithelial cells from various portions of the 
urinary tract. 

Diseases in which Epithelium is increased in the Urine : 

I. Affections of the kidnevs : serious if abundant and 
accompanied by albumin, blood, casts, etc. 

II. Affections of the ureters : serious when as in I. 

III. Leucorrhcea or specific inflammation of vagina. 

IV. Catarrhal inflammation lining membrane of the 
bladder. 

V. Catarrhal or specific inflammation of urethra, 

VI. Strumous diathesis : female children. 

It must be carefully noted that an abundant, amor- 
phous-looking, light, cloudy deposit, consisting of epithe- 
lial cells from the vagina, is found in the urine of females 
when none of these diseases may be present ; this deposit 
will be greatly increased in leucorrhcea. 



156 CLINICAL SIGNIFICANCE OF URINE. 

Iii acid urine the epithelial cells are preserved for some 
length of time, but in alkaline urine they are gradually 
destroyed, becoming first swollen and transparent. 

If, together with casts and albumin, the round cells 
are found, they have probably come from the uriniferous 
tubules, or if there are symptoms of impacted calculus, 
from the pelvis of the kidney ; otherwise from the urethra, 
Cowper's gland, or the prostate. 

Tube Casts. — A urinary sediment may contain tube 
casts ; these are cylinders or moulds formed in the urin- 
iferous tubules and consisting of some transparent mate- 
rial which is formed in or poured out into the canal and 
there made firm, entangling in its meshes whatever may 
be in the tube at the time of its effusion. 

Their presence in the urine is significant of congestion 
or inflammation of the kidney ; this may be (i.) tempo- 
rary or (ii.) permanent. Constant presence of tube casts 
in the urine may indicate serious trouble, if albumin, 
blood, etc., occur, and the quantity of urine is abnormal. 
Diseases in which Tube Casts Appear in the Urine: 

I. All cases of renal congestion and in acute or chronic 

Bright' s disease. 

II. Acute diseases (temporarily): bronchitis, pneu- 
monia, convalescence from scarlet fever. 

III. After heavy doses of various drugs. 

IV. Purulent infection (some forms) ; icterus after 
attempt at asphyxia with charcoal. 

Classification of Casts.— Description.— Voluminous, of 
greater or less length (rarely exceeding -^th of an inch) ; 
variable aspect ; pale or hyaline, granular or covered with 
epithelium; sometimes distinctly, sometimes indistinctly 
outlined ; generally round or club-shaped extremities : 



CLINICAL SIGNIFICANCE OF URINE. 



157 



r 



(a) Very 
pale or 
transpar- 
ent amor- 
phous, 
cylinders. 



< 



With badly defined 
mar gins, often 
twisted or varicose -K 
branching and sub- 
dividing. 



With clear, well-de- f 
fined margins, 
sometimes inter- 
sected bv fractures. 



Uncolored 
bv car- 
mine. 



H 



Mucus 
casts. 



Colored by 
carmine 



- 



fHva- 
lhie or 
waxy 
casts. 



(b) More or less 
dark epithe- 
lial or gran- 
ular cylin- ^ 
ders (200 to 
400 diame- 
ters). 



No line of contour ; epi- 
thelial cells united into 
into a cylinder. Never 
very narrow. 



- 



Epithelial or 
granular 
casts. 



A more or less distinct 
line of contour ; fun- 
damental substance, ^ 
finely £rranular,studded 
with blood corpuscles. 

Any of the above may undergo fatty degeneration. 



Fibrinous or 
blood casts. 



Bright's Disease and Tube Casts. — In acute desquama- 
tive nephritis we may expect to find epithelial casts, as 
well as both large and small hyaline casts, blood and oil 
casts ; when the acute desquamative nephritis has passed 
into the chronic state albumin may be present in the 
urine, but not necessarily casts, for several years. As the 
chronic disease progresses the urine loses its normal color 
and grows more or less colorless, the deposit more dense 
and copious, containing large granular and hyaline casts 
indicative of granular contraction of cortical portion of 

the kidney. 

A few oily casts and cells, together with other caste, 
have no special unfavorable significance, but if albumin 
be found steadily for weeks and months, and oil casts 



158 CLINICAL SIGNIFICANCE OF URINE. 

preponderate in the deposit, there is reason to fear fatty 
degeneration. After scarlet fever in some cases, instead 
of the desquamative tubular nephritis which often results, 
we may find what is called glomerulo-nephritis, indicated 
by presence in the deposit of white cell casts. 

The small, red, granular kidney is indicated often by 
copious amount of urine of low specific gravity, not 
always much albumin, granular casts and scattered epi- 
thelial debris, and late in the disease often large hyaline 

casts. 

Lardaceous degeneration is not always easy to diagnose 
from the urine which, however, may be copious, clear and 
containing no sediment, but in most cases a light cloud 
can be seen containing small, hyaline, and finely granular 
casts with, occasionally, oil casts and cells. It is well to 
bear in mind that Blight's disease should not be diag- 
nosed solelv from observation of certain conditions in the 

mJ 

urine ; it is not the province of this work, however, to 
dwell upon the dropsy, condition of the eye, headache, 
giddiness, twitching or cramp in certain muscles, dry, 
harsh skin, condition of heart, etc., which may be found 
in the course of the malady. 

Haemoglobin in the Urine. — In certain diseases and 
after poisoning by certain substances, the coloring-matter 
of the blood may be found in the urine. Such a condi- 
tion is termed ImmogloUnuria, and differs from "blood" 
in the urine in that no blood corpuscles can be detected 
with the microscope, the coloring matter alone being 
present* ' In such cases the urine may vary in color from 
red -brown to inky black. 

*j 

Circumstances under which Haemoglobin may be Found in 
the Urine: 

I. Severe scurvy and purpura hemorrhagica. 



CLINICAL SIGNIFICANCE OF URINE. 159" 

II. Typhus with dissolution of the blood ; septic fever. 

III. After scarlet fever, after transfusion of blood, and 
occasionally in hemophilia. 

IV. Epidemically, as a disease among the new-born.* 

V. As a paroxysmal disease after exposure to cold or 
under certain malarial conditions (especially in young 

males). 

VI. After poisoning by (i.) phosphorus, (ii.) copper 
sulphate (Starr), (hi.) carbonic acid, hydrocyanic acid 
and arseniuretted hydrogen gasses (inhalation of). 

VII. In chronic lead-poisoniug. 

VIII. After injection of glycerine into the blood. 

The temporary presence of this substance hi the urine 
is not alarming but when it occurs permanently the prog- 
nosis is doubtful. 

Before the diagnosis of haemoglobmuna is made the 
urine should be carefully examined for blood-corpuscles ; 
if none be found some of the granular matter which may 
form the sediment should be dried on a glass slide, com- 
mon salt rubbed into it, a hair laid across, a cover glass 
applied, and a drop of glacial acetic acid allowed to enter 
beneath the cover. If the slide be then warmei and 
subjected to examination with a power of 600 diameters,, 
crystals of hsemin will be seen. Haemin crystallizes in 
rhomboidal tubes. Further examination of some of the 
sediment, with the spectroscope, will bring out the two 
absorption bands between D and E, characteristic of 
oxyhemoglobins 

Blood. — Blood itself may occur in the urine under the 
following conditions : 

I. Kidney troubles, as (i.) acute Bright's disease, (ii.) 

* Seventy-eight per cent of babes born in Dresden during March 
and April, 1879, died of it. 



160 



CLINICAL SIGNIFICANCE OF URINE. 



active or passive congestion, (iii.) cancer or fungous 
growths, (iv.) tubercle, (v.) calculus in pelvis of kidney 
or in ureter, (vi.) parasites, as Bilharzia hcematobia, (vii.) 
pyelitis, (viii.) cancer of the pelvis and ureter, (ix.) 
traumatism. 

II. Bladder and urethral affections. 

III. External injury or violent exercise. 

IV. Administration in large doses of certain drugs, as 
cantharis, potassium chlorate. 

V. Supplementary to haemorrhoids, or asthma. 

VI. Menstruation, uterine or vaginal haemorrhage. 

VII. Intentionally mixed with the urine for the pur- 
poses of^deception. 

Urine containing blood will show with the aid of the 
microscope, blood corpuscles; in such cases the term 
hcematuria is used. 

Urine containing blood will also contain albumin, since 
blood contains albumin ; the physician should not, there- 
fore, jump at the conclusion that Bright's disease is pres- 
ent from finding albumin in urine, which also contains 

blood. 

The following table may aid in the diagnosis of blood 

in urine : 



From Kidneys. 

BLOOD PASSED. 

Bloody urine 
with elongated 
clots from ure- 
ters, is generally 
albuminous, usu- 
ally tube casts 



CHARACTER OF 
URINE. 

Urine smoky or 
blackish-brown,if 
acid ; bright red, 
if alkaline. Forms 
a brownish -red, 
pulverulent mass 



PAIN, ETC. 

Pain when 
moulds of clotted 
blood form in the 
ureters and are 
discharged in the 
urine. 



CLINICAL SIGNIFICANCE OF URINE. 



161 



BLOOD PASSED. 

present, and 
symptoms of 
renal disease. 
Blood brown col- 
ored or like por- 
ter, and not as 
profuse as when 
from bladder. 

Nephritic Colic. 

Frequently 
blood in urine 
from kidneys. 



Benal Cancer. 

Frequent and 
profuse bloody 
urine. 

From Bladder. 

Blood in small 
flaky clots, not 
mixed with urine, 
but passing with 
it. 



CHARACTER OF 
URINE. 

or deposit. Albu- 
min is found as 
well as renal 

casts. 



PAIN, ETC. 



Constant de- 
sire to urinate. 
Sometimes blood 
clots in urine. 



Pus and en- 
cephaloid matter 
present in the ad- 
vanced stages. 

Urine ammon- 
iacal; with tena- 
cious mucus and 
phosphatic depos- 
its — in feeble per- 
sons. Urine al- 
kaline. 



Abrasion or Ulceration of Bladder. 

Blood mixed Frequent de- 



with mucus or 
pus in the urine. 



fll 



sire to urinate and 
urine putrid con- 
taining more o r 
less muco-puru- 
lent matter. 



With pain in 
region of kidneys 
and along the 
course of the 
ureters. 

Tumor found 
in the loins ; and 
deep-seated pains. 



Dull pain in 
region of bladder 
and at its neck; 
frequent desire to 
urinate. Some- 
times retention 
from a coagulum 
in the urethra. 

Acute burning 
pain in pelvic cav- 
ity, with uneasi- 
ness. 



162 



CLINICAL SIGNIFICANCE OF URINE. 



BLOOD PASSED. 

Malignant Disease. 

Blood dark- 
colored, with pu- 
t r i d , offensive 
matters. 

From Urethra. 

Blood coming 
without urine, 
in drops or in a 
small stream. 
Sometimes small 
clots. 

Vesical Calculus. 

Blood in urine 
after exercising ; 
or a drop or two 
with pain in the 
last expulsive ef- 
fort at urination, 
and with pain at 
the time. 



CHARACTER OF 
URINE. 

Urination often 
difficult, painful, 
and with frequent 
desire to void the 
urine. 

The first jet of 
urine only is 
bloody, the bal- 
ance becoming 
clearer and natu- 
ral. 



Urine passed 
often during the 
day ; apt to be of 
a florid color, and 
the desire to urin- 
ate caused by any 
movements or ex- 
ercise. 



PAIN, ETC 

More or less 
severe pain in vi- 
cinity of the dis- 
ease. 



Perhaps sore- 
ness at the part 
from which the 
blood issues. 



Probable Prostatic Hypertrophy. 

Blood intimate- Urine frequent 

ly mixed with especially during 

urine, dark col- the night, 
ored and not 
much altered by 
circumstances. 

Chronic Cystitis or Chronic Inflammation 

Urine contains Urine frequent 

blood - corpuscles, and in smal 



Pain in penis 
or perineum, felt 
after (and often 
before) urinating, 
especially when 
pain is increased 
by exercise. Usu- 
ally pain at end 
of penis. 



More or less 
constant irrita- 
tion at neck of 
bladder.. 



if any haemor- 
rhage be present. 
Mucus increased. 



amount during 
the day (frequent- 
ly alkaline, fetid). 



of Neck of Bladder. 

Pain low down 
in belly. Slight 
pain in expelling 
the last drop of 
urine. 




CLINICAL SIGNIFICANCE OF UEINE. 



163 



BLOOD PASSED. 

Chronic Prostatic 

Blood rarely if 
ever passed. 



CHARACTER OF 
URINE. 



Urination un- 
duly frequent; a 
small muco-puru- 
1 e n t discharge 
from urethra ; 
urine a little 
cloudy. 

Distended Mucous Membrane of Bladder. 



PAIN, ETC. 

Diminished 
sexual desire. 
Pain at end of 
penis. Dull pains 
in perineum and 
vicinity. 



Urine difficult 
and incomplete ; 
passes by drops 
involuntarily, but 
in full stream on 
catheterization. 



Pain in penis 
or perineum felt 
before urinating. 



Chronic Inflammation of Mucous Coat of Bladder. 



Blood occasion- 
ally observed, es- 
pecially when ul- 
cerations or 
abscesses have 
formed. 



Urine passed 
often during the 
day in small 
quantities at a 
time; alkaline. 
Mucus increased. 



Dull pain in 
region of bladder. 
Heaviness in peri- 
neum ; weakness 
in back. 



It is wise to have the urine passed into two vessels — say 
an ounce or two in the first and the balance in the second 
vessel. 

In cold weather urates are often deposited in the urine 
giving it a lurid appearance which may probably frighten 
the patient into a belief that blood is present ; application 
of gentle heat will cause the fluid to clear if the urates 
are the constituents of the deposit. 

In case considerable albumin and tube casts are found 
together with blood, renal disease may be suspected (see 
Wood's Observations on Quantity). In bladder troubles 



164 



CLINICAL SIGNIFICANCE OF URINE. 



blood may be found and a small amount of albumin cor- 
responding to the blood but no tube casts ; likewise in 
urethral affections. 

Pus. — According to Sir Henry Thompson, " pus may, and 
most commonly does, proceed from some local condition 
of the bladder." The abstract significance of pus in the 
urine is a suppurative process in the urinary tract (uro- 
poietic system) or an abscess communicating with it. 

The following table may be of value in determining 
the cause of pus in the urine : 



PAIN, ETC. 

Prom Bladder. 

Symptoms of acute or 
chronic disease of the blad- 
der, as strangury, etc. 



Prom Ureters. 

Slight colicky pains 
along the course of the 
ureter. 

From Urethra. 

That referable to gonor- 
rhoea, etc. 



Prom Vagina. 

Symptoms referable to 
leucorrhoea. 



OBSEBVATIONS. 

Urine alkaline. Triple 
phosphates present in fresh 
urine. If urine be drawn 
off with catheter in severe 
cases spindle-shaped cells, 
smaller than the vesical epi- 
thelial cells and nucleated, 
will be found with micro- 
scope. 



Purulent fluid may be 
pressed out of the urethra, 
between micturitions and 
"shreds" may be seen in the 
urine. 

Abundant pavement epi- 
thelium of vagina, under 
microscope. 



CLINICAL SIGNIFICANCE OF URINE. 



165 



PAIN, ETC. 

From Kidney Pelvis. 

Lumbar pains. Absence 
of bladder or urethra signs. 

From Kidney Parenchyma. 

Local symptoms very 
slight. 

■ 

From Abscesses Bursting into 

Symptoms referable to an 
abscess. 



OBSERVATIONS. 

Urine acid. Renal casts. 
Transitional epithelium seen 
with microscope. 

Long-continued presence 
of pus in urine. 

Urinary Passages. 

Sudden presence of large 
amount of pus in urine. 



If pus be found in the urine for a few days and then 
disappear, we may conclude that the affection is super- 
ficial and not serious ; if, on the other hand, pus be found 
steadily in the urine from day to day, some deep-seated 
and extensive alteration is indicated. 

Spermatozoa. — Spermatozoids frequently may be found 
in the urine of males in a state of health. Constant 
presence of them together with other more important 
symptoms may indicate masturbation. 

Conditions under which Spermatozoa are found in the 
Urine. 

I. After coition or nocturnal emissions. 

II. During typhus. 

III. In so-called " spermatorrhoea." 

Method of Collection. — Rouvier's method for collecting 
spermatozoa is as follows : Collect the urine for twenty- 
four hours, let it settle for two hours, decant the urine 
from the sediment, collect the latter in a test-tube and 
shake it up with ether. On standing the ether will come 
to the top, when on draining it off with a pipette and 
adding a few drops of distilled water the microscope will 
show the spermatozoa. 



166 CLINICAL SIGNIFICANCE OF URINE. 

Cancer Elements. — In cases of cancer of any part of the 
urinary apparatus as the bladder, two different forms of 
cancer elements are sometimes observed: (a) isolated 
cancer-cells; (5) pieces of cancer-tissue. 

Cancer-cells are of great variety of form often quite 
oddly formed ; they may resemble epithelial cells of the 
urinary passages. It is only from an abundant appearance 
of peculiar and many-formed cells that a malignant growth 
can be recognized with any certainty. 

Fragments of villous cancer may be seen in the sedi- 
ment of urine. 

If the tissue is well preserved, which it seldom is, under 
a power of 300 diameters a tree-like formation similar to 
fringe may be seen ; usually, however, sloughed off and 
much altered pieces of tissue only appear in the sediment 
and the identification of these is very difficult. 

If crystals of haematoidin (small rhomboid prisms in- 
soluble in water, alcohol, ether, acetic acid, glycerin, 
dilute mineral acids and dilute alkalies, of a red or yellow 
color) be found imbedded in tissue in urinary sediment, 
the diagnosis of old hemorrhagic and necrotic tissue, as 
found in villous tumors, may be made. Sometimes on 
treating necrotic cancerous tissue with glycerin, crystals 
of hsematoidin may be seen, either as rhomboids or small, 
yellow, grassy tufts. 

Sometimes with a low power, 120 diameters, thicker 
and darker colored, tuft-shaped, branching forms may be 
observed in necrotic flakes. 

If the urine is strongly alkaline the villous tissue may 
be so changed and incrusted with phosphates that a diag- 
nosis can scarcely be made. 

Fungi: 

Sarcinae appear to be formed in the urine before it is 



CLINICAL SIGNIFICANCE OF UEINE. 167 

voided ; they are found in both acid and alkaline urine 
generally associated with some disorder of the urinary 
organs. 

Bacteria in the urine show that putrefactive changes 
have set in; the urine containing them soon loses its 
transparency and deposits a sediment of a cloudy appear- 
ance ; its odor becomes offensive and the reaction soon 
ammoniacal. 

Mould Fungus (Penicilium glaucum) is often found in 
acid urine and grows luxuriantly in albuminous urine. 

Yeast or Sugar Fungus (Torula cerevisiae) grows 
luxuriantly in diabetic urine exposed to a moderate tem- 
perature. It has been found in urine in which no sugar 
could be demonstrated. 



APPENDIX. 



The contents of the appendix are as follows : 

Examination of Urinary Calculi. 
Effect of Reagents on Normal Uriue. 
Changes in Normal urine on Standing. 
"What to Look for in the Urine in Disease. 
Micro-chemical Summary (Deposits). 
Eare and Occasional Constituents of the Urine together 
with Normal Constituents occurring in Small Amount. 
Eesults of Analyses recently made by the Author. 
Glossary of Terms used in Parts I. and II. 
The Use of « Dry" Tests for Albumin and Sugar. 

EXAMINATION OF URINARY CALCULI. 

The chemical elements in calculi are the same as those 
in deposits. 

Method of Procedure. 

Eeduce calculus to powder in agate mortar. 

Place some of this upon platinum foil. 

Heat in the flame of an alcohol lamp to a red heat. 

If the heating is accompanied by a flame the calculus 
contains either: (a) fatty matters, (5) cholesterin, or (c) 
eystin. 

Take some of the powdered calculus which has not 
been heated and treat it with ether ; if it dissolves, fatty 
matters and cholesterin are indicated ; if it does not 
dissolve, take a fresh amount and add ammonia to it ; if 
it dissolves, eystin is indicated. Moreover, the odor of 



170 APPENDIX. 

cystin is nauseous, and its flame is bluish-green in color. 
Suppose now the heating of some of the powdered cal- 
culus was not accompanied by a flame, then the calculus 
consists of one or more of the following : 

Uric acid, Calcium phosphate, 

Ammonium urate, Ammonio-magnesium phosphate, 

Sodium urate, Calcium oxalate, 

Calcium urate, Xanthin, 

Magnesium urate, Fibrin. 

To distinguish the members of the above list observe 
when heating to calcination whether (a) no residue is left, 
(b) a slight residue, or (c) a considerable residue. Calculi 
which, on being calcined, leave no residue are either 

Uric acid Xanthin or 

Ammonium urate, Fibrin. 

Uric acid and ammonium urate calculi are distinguished 
from the two others by the murexid test ; take a fresh 
amount of the calculus which has not been heated, place 
it on porcelain, add a little strong nitric acid, heat gently 
until evaporation, let cool, add ammonia. Magnificent 
red color indicates presence of uric acid or urates. 

If the murexid test, carefully performed, gives no results 
take a fresh amount of the calculus and add solution of 
potassium carbonate 5 if it dissolves, xanthin is indicated ; 
if it does not dissolve, test for fibrin which is soluble in 
caustic potash solution, has an odor of burnt horn and is 
precipitated from solutions by potassium ferrocyanide. 

Those calculi which leave a slight residue on incinera- 
tion are urates of sodium, calcium and magnesium, and 
may be recognized by the murexid test. 

Those calculi which leave a considerable residue on 
incineration are calcium oxalate, calcium phosphate, 
ammonio-magnesium phosphate. 



APPENDIX. 171 

If the calculus is calcium oxalate a small portion of it 
will not dissolve in acetic acid ; effervescence takes place 
when a drop of nitric acid is poured on a little of the 
residue after ignition. 

Calculi of ammonio-magnesium phosphate and calcium 
phosphate ordinarily occur together and may be recognized 
by melting to a white enamel-like mass on incineration ; 
hence a calculus composed of these two substances is 
called & fusible calculus. 

Observations : 

Calculi do not always consist of some one or two con- 
stituents, sometimes they contain several, hence before 
proceeding to examination of a calculus it is advisable to 
saw it in two through the centre with a jeweler's saw and 
notice whether it is built up of distinct layers or ap- 
parently consists of one substance. If the former is the 
case, carefully scrape off portions of each layer and 
examine them separately. If the calculus is in fragments, 
select fair specimens of about half a grain or a grain each 
and crush under the blade of a knife. 

Most calculi have a nucleus which is sometimes a 
foreign body upon which the urinary sediments deposit 
and form a crust. Ketained gravel may also become the 
nucleus of a calculus, in which case the nucleus will be 
apt to differ from the rest of the calculus in chemical 
composition. Sometimes the calculus has a vacant space 
in its interior ; in this case the nucleus consisted of mucus 
which later became dry. In rare cases the nucleus rattles 
within the stone, which is to be. explained in the same 
wa y> by the drying up of the mucus. Sometimes the 
calculus is made up of gravel or several small stones 
which are united by a cement, and which sometimes have 



172 APPENDIX. 

the same chemical composition as the calculus and some- 
times a different one. — Vogel. 

EFFECTS OF REAGENTS, ETC., ON NORMAL TJRINE. 

Boil normal urine and it should be clear. 
Acids (concentrated) added to the urine generate, on 
boiling the same, a peculiar nauseous odor and the urine 
becomes more or less dark. 

Alkalies produce a cloudiness in the urine caused by 
precipitation of phosphates (earthy). 

Barium chloride solution added to urine acidified with 
hydrochloric acid precipitates the sulphuric acid of the 
urine in the form of barium sulphate. 

Silver nitrate solution added to urine precipitates the 
phosphates and chlorides as silver phosphate and silver 
chloride ; if nitric acid be added to urine and then silver 
nitrate solution, silver chloride alone is precipitated. 

Iron chloride solution precipitates the phosphoric acid 
if acetic acid has first been added. 

Lead acetate solution precipitates the chlorides, sul- 
phates and phosphates as lead salts ; it is useful, therefore, 
when we desire for purposes of analysis to free the urine 
from these constituents. 

Oxalic acid or oxalate of ammonium precipitates the 
lime of the urine as lime oxalate. 

Mercuric nitrate produces in urine, from which the 
sulphuric and phosphoric acids have been removed, a 
cloudiness which disappears; further addition, now, of 
mercuric nitrate causes a white, insoluble compound of 
mercuric oxide and urea to separate. 

Alcohol produces a cloudiness which disappears on 
dilution with water. 



APPENDIX. 173 

CHANGES IN NORMAL UEINE ON STANDING. 

After standing some time normal urine begins to 
change; fermentation, so-called, begins, due, according to 
Scherer, to decomposition of mucus from the bladder, 
forming a fungus very like the ferment Mycodermae Cere- 
visiae, and then the coloring matter decomposes. 

In consequence of this the color of the urine usually 
grows paler, the reaction more acid, due to the fermenta- 
tion of lactic and acetic acids ; a sediment forms, red in 
color, consisting of uric acid, urates and mucus. These 
are the phenomena of so-called acid fermentation, but 
further on in process of time the so-called alkaline fer- 
mentation may set in — in some cases this may happen 
before and without acid fermentation — in which the urea 
of the urine is decomposed into acid ammonium carbon- 
ate and free ammonia; the urine acquires a strong 
ammoniacal odor and effervesces strongly on addition of 
acids. The sediment will now contain triple phosphate 
crystals, and, with the microscope, fungus threads, infu- 
soria, and ammonium urate may be seen. Alkalies added 
to the urine in this stage cause an abundant generation of 
ammonia. 

WHAT TO LOOK FOE IN THE URINE OF 

DISEASE. 

• 

If the urine contains albumin look with the microscope 
for tube casts and other evidences of kidney disease. If 
the urine contain a small amount of albumin it is well to 
be on one's guard lest pus or blood should be overlooked. 
In albuminous urine the sediment will often contain fungi; 
these should not be mistaken for blood-corpuscles. If 
the urine be pale, of high specific gravity and sweetish 
odor, test for sugar. 



174 APPENDIX. 

When a large quantity of urine is passed daily, contain 
ing no sugar, estimate the solids so as to recognize dia- 
betes insipidus, if present. In acute febrile disturbances 
estimate the amount of urea from day to day, and exam- 
ine deposit for urates in large amount ; in inflammations 
attended by exudation, watch the chlorides ; albumin is 
often found in these conditions and if the kidneys become 
involved, casts, cells, etc., and in severe cases, blood and 

pus corpuscles. 

The re-appearance or increase of chlorides in an acute 
inflammation is deemed favorable; the appearance of . 
albumin unfavorable. 

Among many acute febrile processes there are certain 
ones where examination of the urine is of especial value ; 
these are : 

I. Icterus. 

II. Acute atrophy of the liver. 

III. Acute lung diseases. 

IV. Heart diseases. 

V. Peritonitis. 

VI. Meningitis. 

VII. Acute articular rheumatism. 

I. 

In Icterus look for biliary coloring matters in the urine ; 
whether found or not, next examine the urine for alhu- 
min. If albumin be present the case is one of icterus 
gravis and small amounts of biliary acids may be detected. 

II. 

In Acute Liver Atrophy look for leucin and tyrosin, epi- 
thelial casts, fibrinous cylinders, kidney epithelium and 
isolated blood-corpuscles in the sediment ; examine also 
for albumin which is generally very abundant. Test for 



APPENDIX. 175 

the chlorides which generally are absent. Urates and 
biliary matters will also be present. 

III. 
In Acute Lung Diseases the larger the amount of urates 
the more insufficient the respiration. 

IV. 
In Heart Diseases test for albumin. 

V. 

In Peritonitis look for increase of indican. (Senator.) 

VI. 

In Meningitis observe whether the specific gravity is 
high and whether on boiling the urine the earthy phos- 
phates separate. (In typhus the earthy phosphates do 
not thus appear). The differential diagnosis between 
typhus and meningitis cannot invariably be determined 
as above. 

VII. 

In Acute Articular Rheumatism expect to find the earthy 
phosphates much increased ; the sediment should contain 
rose-red urates and oxalate of lime colored by uroerythrin ; 
if pericarditis be dreaded or exist, estimate the chlorides 
often. The earthy phosphates will decrease with the 
chlorides on advent of pericarditis, but the uroerythrin 
will appear still more beautiful. 

In Non-Febrile Diseases and in chronic diseases for the 
most part, observe that the color of the urine is not dark 
reddish -yellow and urates are not present in large amount. 

Among these affections the following possess certain, 
characteristic peculiarities : 

I. Chlorosis. 

II. Hysteria. 

III. Diabetes mellitus. 



176 APPENDIX. 

IV. Chronic diseases of the spinal cord. 

V. Rachitis and osteomalacia. 

VI. Bone diseases involving a great part of the 
skeleton. 

VII. Chronic articular rheumatism.* 

VIII. Gout. 

IX. Intermittent fever. 

X. Chronic liver affections. 

XI. Chronic skin diseases. 

XII. Scurvy and purpura hemorrhagica. 

XIII. Melansemia. 

XIV. Leucaemia. 

I. 
Chlorosis shows a very pale urine of low specific gravity. 

II. 
Hysteria is like chlorosis, but at times the specific grav- 
ity is greater and a large amount of indican present. 

III. 
In Diabetes Mellitus test the urine for albumin which 
appears in considerable quantity in the later stages of the 
disease. In the sediment look for fungi. 

IV. 
In Chronic Diseases of the Spinal Cord test for in- 
creased indican and earthy phosphates 

V. 
In Rachitis and especially in osteomalacia some authors 
claim the earthy phosphates to be strongly increased and 
to form a copious sediment. 

VI. 
In Bone Diseases involving a great part of the skeleton, 
expect to find increase of carbonate and oxalate of lime in 



APPENDIX. 177 

the sediment and increase of earthy phosphates partly in 
solution and partly in sediment. 

VII. 
In Chronic Articular Rheumatism expect to find a sedi- 
ment rich in urates and calcium oxalate; also a great in- 
crease of earthy phosphates. 

VIII. 
In Gout estimate the uric acid which is generally ex- 
creted in diminished amount ; at times free uric acid is 
found in the sediment. 

IX. 
In Intermittent Fever during the cold stage an increased 
amount of light, clear urine is voided. 

X. 

In Chronic Liver Affections, even when no fever exists, 
the urine may be dark, acid, and of high specific gravity 
and diminished quantity. 

Coloring matters are increased ; in the sediment observe 
rose-red urates and often small amount of lime oxalate. 

XI. 
In Chronic Skin Diseases, especially if the function of 
perspiration is partly destroyed, test the urine for albumin 
and examine the deposit for evidences of kidney compli- 
cations. 

XII-XIII. 
In Scurvy and Purpura Hemorrhagica test for blood 
in the urine ; also in melancemia. 

XIV. 
In Leucaemia look for uric, hippuric and lactic acids. 

tis 



178 APPEHDIX. 

MICRO-CHEMICAL SUMMARY. 

(Unorganized Deposits.) 

' a. If a deposit is partly or wholly soluble in acetic acid 
look in a fresh amount of the deposit, to which nothing 
has been added, for triple phosphate and calcium phos- 
phate. 

i. If a deposit is slowly soluble in acetic acid, giving 
rise to colorless tablets of uric acid, look for urates. 

c. If a deposit is insoluble in acetic acid, look for uric 
acid, hippuric acid, oxalate of lime, cystin, tyrosin (not 
too strong acid). 

a. Triple phosphate: very large, transparent crystals, 
generally triangular prismatic in form. Found in alka- 
line urine only. 

Calcium phosphate: generally amorphous; sometimes 
crystalline in pale, faintly acid urine with a tendency to 
alkaline fermentation. Crystalline calcium phosphate 
shows rods, either separate, in stellate groups or is sheaf- 
like bundles. 

i. Urates are generally amorphous ; the urate of soda 
may show "hedge-hog" crystals or prismatic crystals 
arranged in star-like masses. Found in acid and neutral 

urine. 

c. Uric acid : large, red, yellow or brown crystals, gen- 
erally four-sided rhombs ; found only in acid urine ; best 
seen with a low power, 100 or 200 diameters. 

Oxalate of lime : very small, octahedral (letter envel- 
ope) or dumb-bell crystals, best seen with a power of 
from 400 to 600 diameters. 

Cystin: colorless, hexagonal tablets overlapping one 
another; sometimes square prisms. Soluble in ammonia 
and in this manner differentiated from uric acid which 
is not. 



APPENDIX. 179 

Tyrosin : (generally) deep-yellow, fine, short, acicular 
prisms in bundles, tufts, sheaf-like collections or spicu- 
lated balls. They are insoluble in not too strong acetic 
acid. 

Hippuric acid : very rare deposit in acid urine, resem- 
bles triple phosphate microscopically, but insoluble in 
acetic acid. 

d. If a sediment contains none of the above or some- 
thing else beside the above, look for : leucin, xanthin. 

Leucin : (generally) yellowish spheres with sharp con- 
tours showing, with good light, radii and delicate concen- 
tric lines. Insoluble in ether ; while fat (which leucin 
resembles microscopically) is soluble. 

Xanthin : Whetstone crystals soluble on heating. (Uric 
acid not dissolved by heat.) 



MICRO-CHEMICAL SUMMARY. 

(Organized Deposits.) 

a. If the urine is turbid when first voided, examine the 
sediment for organized bodies. 

b. If with # power of from 400 to 600 diameters, 
small, round or oval bodies be seen, look for : red blood 
corpuscles, white blood corpuscles (leucocytes, pus cor- 
puscles), fungus spores, spermatozoa. 

Differentiation. — To a portion of the sediment add a 
drop of carmine solution; if the round or oval bodies 
become colored, to another portion of the deposit to which 
nothing lias been added, add acetic acid. (This may be 
done by introducing a drop of the acid beneath the glass 
cover — see Introduction). If the bodies become pale 
and two or three nuclei appear, leucocytes are present in 
the deposit. 



180 APPENDIX. 

If the round or oval bodies do not become colored by 
the carmine, to a fresh amount add dilute acetic acid ; if 
the bodies swell, or shrink, presenting a "raspberry" 
appearance without nuclei, especially if transparent or of 
a faintly yellowish color, red blood corpuscles are present. 
(Verify by study of their appearance, characteristics, etc). 

If neither carmine nor acetic acid causes any change in 
appearance, look for spermatozoa and fungi ; spermatozoa 
have the general appearance of minute tad-poles ; if the 
latter be not found, set the slide aside for a few days and 
if on re-examination the bodies have germinated, fungi 

are present. 

c. If with the same power as in (b) larger bodies are 
seen, of variable form, such as round, oval, lamellar, cylin- 
drical, fusiform, caudate or irregular, showing nuclei and 
granular contents, epithelium is present. Add acetic acid 
and the bodies become pale and the nuclei are distinctly 
exhibited. To a fresh portion of the sediment add car- 
mine and they become colored. 

d. If cylindrical bodies be seen, tube-casts may be 
present. (See Tube Casts, page 156.) 

e. If with a power of 500 diameters and upwards very 
small, transparent bodies be seen, generally exhibiting 
active vibratory movements, bacteria may be present. 
Acetic acid arrests their motion. 

/. If the bodies present a filamentous or fibrillary appear- 
ance, look for thallus of fungi, fibrin, mucus. 

Differentiation.— To a portion of the sediment add 
acetic acid ; if no change thallus may be present. If on 
addition of acetic acid a swollen, transparent, amorphous 
mass appear, fibrin may be present ; if the appearance is 
more distinct and punctated or striated, mucus may be 
present. 



APPENDIX. 181 

BARE OR OCCASIONAL CONSTITUENTS OF THE 
URINE, TOGETHER WITH NORMAL CONSTITU- 
ENTS, OCCURRING IN SMALL AMOUNTS. 

Among the normal constituents of urine occurring in 
small amount may be reckoned kreatin, xanthin, hypo- 
xanthin (?), oxaluric acid, succinic acid, carbolic acid, 
iron, ammonium salts, silicic acid, nitrates and nitrites, 
hydrogen peroxide, various coloring matters. 

Kreatin. — Not much can be definitely said about the 
physiological significance of kreatin ; it stands nearer to 
urea than to the protein substances. 

Xanthin. — This substance is found in normal urine in 
small amount ; it is a rare constituent of deposits and 
calculi. When occurring as a deposit it appears under 
the microscope as small, oblong plates; it is soluble in 
ammonia, caustic potash and in the strong mineral acids, 
when heated. When xanthin is found in a deposit its 
significance is said to be liability to cause the formation 
of calculi containing it. 

- Hypoxanthin. — This is a substance closely allied to 
xanthin. 

Oxaluric Acid. — This substance occurs in normal urine 
in the form of oxalurate of ammonium. 

Succinic Acid. — According to Salkowski this substance 
does not occur in human urine; other observers have 
found it following the ingestion of various articles of diet, 
especially asparagus. Neubauer suggests that inasmuch 
as wine and other fermented drinks contain not incon- 
siderable quantities of this acid and the latter, at least in 
part, goes over into the urine unchanged, we have a really 
frequent source for its occurrence in normal urine. 

Carbolic Acid. — Only a very small quantity of this acid 
can be separated from normal human urine ; when pres- 



182 APPENDIX. 

ent in the urine in excess (without being given internally 
or used externally) it is indicative of the intensity of 
putrid fermentation in the intestine ; in septic maladies, 
empyema with pleural fistula, tetanus, and acute tubercu- 
lous peritonitis, the amount of carbolic acid in the urine 
is increased. To detect or to estimate it the urine may 
be distilled with sulphuric acid and precipitated with 
bromine water. Other acids very similar to it called 
taurylic, damaluric and damolic, are also found in the 
urine. 

Iron. — Iron for the most part is found only in very 
minute quantity in the residue of urine after ignition. If 
the urine contain blood, iron is more easily detected in the 
ash. According to Magnier the normal amount averages 
0.007 gramme to the litre of urine. Quillart's method of 
detecting iron in the urine is to treat the residue with 
sulphuric acid, then, after cooling, with nitric acid, evap- 
orate gently, dissolve in water acidulated with a drop of 
nitric acid and test the solution for iron with the usual 
reagents of this metal. Preparations of iron taken in- 
ternally greatly increase the amount of iron in the urine. 

Hypo-Sulphurous Acid. — This acid was found by Strum- 
pell in the urine of a typhoid fever patient. 

Ammonium Salts. — According to Woodman and Tidy 
the amount of ammonia on an average in the normal 
urine of twenty-four hours is 0.162 gramme. It dimin- 
ishes one-half in acute articular rheumatism, albumin- 
uria, phthisis and nervous diseases. It sinks to one- 
quarter the normal amound in erysipelas, variola, typhus 
and typhoid fevers. It is said to disappear almost wholly 
from the urine shortly before death. 

Silicic Acid. — This acid occurs only in very small 
amount in the urine. 



APPENDIX. 183 

Nitrates and Nitrites. — According to Schoenbein, every 
normal urme contains small amounts of nitrates coming 
from food and water. The nitrates are gradually reduced 
to nitrites by the urinary fermentation which soon takes 
place on standing. Hydrogen peroxide according to the 
same authority may be found in normal urine. 

Coloring Matters. — Various coloring matters have been 
described as occurring in normal urine, such as urobilin, 
urochrom, uroxanthin, uroglaucin and urrhodin, and uro- 
erythin. 

Among the abnormal constituents found occasionally 
in the urine we may mention fibrin, casein, albuminose 
paralbumin and paraglobulin, peptone and nephrozymase, 
among the substances related to albumin ; amoug those 
related to sugar, alkapton and inosite ; miscellaneous sub- 
stances : biliary acids, cholesterin, lactic acid, the volatile 
fatty acids, benzoic acid, sulphuretted hydrogen, allan- 
toic, alloxan, cystin, leucin, tyrosin, oxymandel acid, oxy- 
phenic acid, uro-rubro-hamiatin and uro-fusco-ha?matin, 
acetone, alcohol and ethyldiacetic acid. 

Fibrin. — In urine containing blood as in severe inflam- 
mation of the kidneys and urinary passages, fibrin may 
separate hi somewhat large masses. Ackermann found 
it in the urine in galacturia. Isolated cases have been 
observed also in which fibrin separated from the urine 
partly as a gelatinous mass and partly as granular or fib- 
rillaied clumps. The microscope will show the regular 
fibrin cylinder rolled -up with sharp contour and yellow in 
color. 

Paralbumin and Paraglobulin. — These substances have 
been found in the urine in cases of Bright's disease ; they 
may be demonstrated by diluting the urine with water 



184 APPENDIX. 

after filtration until its specific gravity becomes 1003 or 
1002 and then passing carbonic acid through the dilute 
fluid. Sometimes the dilution with water is enough to 
cause a turbidity due to them, especially in case of paral- 
bumin. 

Peptone. — According to Senator peptone can be de- 
tected in every albuminous ui;ine ; Gerhardt has observed 
it in urine free from albumin, either as a forerunner or as 
a consequence of albuminuria. If the urine contain 
albumin remove the latter by heat, filter, add to the fil- 
trate three times its volume of alcohol. Shake well, dis- 
solve the precipitate which takes place — after filtering 
and washing with alcohol — in water and on heating with 
nitric acid a yellow coloration is given it. 

Mephrozymase. — According to Beehamp three times its 
amount of 88 to 90 per cent alcohol will precipitate from 
every normal urine a substance capable of changing 
starch into sugar at 60° to 70° O. 

Alkapton. — This substance was first observed by Boe- 
decker in the urine of a man forty-four years old, who 
suffered repeatedly from severe cough and expectoration 
after typhoid fever. The urine contained not over one 
per cent of sugar. Fuerbringer detected it in the urine of 
a man twenty-nine years old troubled with lung disease. 
Johnson detected it on one occasion and, recently, Arm- 
strong observed it in the urine of a child three years of 
age. According to Boedecker urine containing alkapton 
turns brown on addition of caustic potash solution, with- 
out heat, and strongly reduces a solution of copper. In 
the case reported by Armstrong the urine darkened on 
addition of caustic potash solution, but Trommer's test 
being applied partial reduction only of the copper salt 
took place. Alkapton does not ferment like sugar, and 




APPENDIX. 185 

although usually classified with the sugars Smith thinks 
it probable that it belongs to the aromatic compounds. 
(See Brenzcatechin). 

Inosite. — Neukomn found this substance in the urine 
of Bright's disease and m diabetic urine. Gallois investi- 
gated the urine of 102 patients, but found inosite in only 
seven cases ; five of these were cases of diabetes and two 
Bright's disease. 

Lactose. — In women, milk sugar (lactose) appears in 
the urine from twenty-four to forty-eight hours after the 
weaning of children, etc. 

Biliary Acids and Cholesterin. — The biliary acids have 
been found at times in the urine of pneumonia without 
the biliary coloring matters. Otherwise they are found 
in company with the latter. To detect biliary acids in 
the urine add to it a little cane sugar, then dip into it a 
piece of filter paper ; allow the latter to dry and by means 
of a glass rod place a drop of pure concentrated sulphuric 
acid on it and in about a quarter of a minute a beautiful 
violet color will appear. According to Dragendorff a 
small quantity of biliary acids will often be found in 
healthy urine. Occasionally taurin is found in the urine 
of icterus. 

Cholesterin appears to have been found in the urine of 
patients suffering from fatty degeneration of the kidneys. 
To detect it collect the sediment and dry the latter over 
a water-bath ; next, digest in a mixture of alcohol and 
ether. Filter, concentrate by evaporation and upon cool- 
ing crystals of cholesterin will form in more or less pro- 
fusion. Use a power of 300 or 400 diameters and very 
thin, rhomboidal or rectangular tables will be seen, fre- 
quently showing a break on one of the borders, and ordi- 
narily overlapping one another. 



186 APPENDIX. 

Lactic Acid, etc. — Lactic acid is said to be more or less 
constantly present in the urine of those suffering from 
pulmonary catarrh and many febrile diseases. Lehmann 
found it always present in urine containing much oxalate 
of lime. According to Schultzen and Kiess, paralactic 
acid occurs abundantly in the urine after phosphorus- 
poisoning. It has also been found in the urine in acute 
atrophy of the liver/ trichinosis, and osteomalacia. There 
are no characteristic tests for lactic acid ; it is identified 
by the microscopic appearance of some of its salts. 

Volatile Fatty Acids. — Formic acid occurs in the urine, 
according to Buliginsky and Thudichum; acetic acid 
appears in the urine as soon as it has begun to ferment ; 
propionic acid occurs in fermenting diabetic urine, and, 
according to Salkowski in normal urine ; butyric acid is 
rarely found in normal urine, more frequently in abnor- 
mal, being, it is supposed, one of the results of the meta- 
morphosis of leucin; baldrianic or valerianic acid has 
been found in the urine of typhoid fever, variola, and 
acute atrophy of the liver. 

Benzoic Acid.— In putrefying urine benzoic acid may 
be found, due to the decomposition of hippuric acid. 
Hilger found it in the urine after partaking largely of 

asparagus. 

Sulphuretted Hydrogen.— This substance is only found 
in the urine in rare cases, as in violent cystitis from decay 
of albuminous urine in the bladder ; when the urine con- 
tains it the smell of rotten eggs is at once no deed. Such 
urine blackens paper moistened with sugar of lead 

solution. 

Allantoin.— Schottin found allantoin in the urine after 

large amounts of tannic acid had been taken. < 

Alloxan. — According to G. Lang this substance has 



APPENDIX. 187 

been met with in the urine of a patient suffering from 
heart disease. 

Cy still. — Cystin often occurs dissolved in the urine and 
may be precipitated with acetic acid. It also occurs as a 
sediment mixed with urate of sodium ; as a calculus its 
occurrence is rare. Not unfrequently, however, large 
concretions of almost chemically pure cystin are passed 
with urines containing cystin as a sediment. The little 
stones of yellow color and crystalline structure vary from 
the size of the head of a pin to that of a pea. Urine con- 
taining cystin is generally paler than healthy urine, fre- 
quently of an oily appearance, with occasionally a green- 
ish tint and usually of low specific gravity. Its odor is 
similar to that of sweet briar, but on decomposing it 
exhales sulphuretted hydrogen and some little ammonia. 
It forms white or pale fawn-colored amorphous deposits; 
under the microscope it is seen as colorless, transparent, 
six-sided plates or prisms, resembling the hexagonal 
plates of uric acid. They are, however, soluble in am- 
monia. To test a deposit for cystin, treat it with acetic 
acid and boil, by which means urates and phosphates will 
be dissolved ; let the sediment which is left undissolved 
settle, decant the urine and add to the sediment nitric 
acid. Heat, and the sediment, if cystin, dissolves leav- 
ing a reddish-brown mass on evaporation. If the micro- 
scope has shown us hexagonal plates or square prisms as 
well, we are able to identify cystin. Its clinical signifi- 
cance is unknown save its liability to cause formation 
of calculus. 

Leucin and Tyrosin. — These substances have been 
found in the urine in cases of acute yellow atrophy of the 
liver, phosphorus-poisoning, small-pox and various exan- 
themata ; their presence, nevertheless, is not confined to 



188 APPENDIX. 

the urine of these diseases, as they have been noticed in 
the urine of some nineteen others. In lighter cases leu- 
cin alone may be present but the appearance of tyrosin is 
deemed significant of grave conditions. Under the micro- 
scope leucin appears in the form of spheres which, if the 
illumination be sufficient, will exhibit radiating and con- 
centric striae ; tyrosin shows very fine, long, delicate, silky, 
acicular prisms, arranged in bundles, tufts, or sheaf -like 
collections, often crossing each other, or forming spicu- 
lated balls. Tyrosin crystals are often colored yellow by 
presence of bile pigments. 

Oxymandel Acid. — This substance, supposed to spring 
from tyrosin, has been found in the urine in cases of acute 
yellow atrophy of the liver, together with leucin, tyrosin, 
and paralactic acid. A new aromatic acid was obtained 
by Schultzen and Eiess in the urine of phosphorus-poison- 
ing ; the material was not sufficient for accurate investi- 
gation. 

Oxyphenic Acid (Brenzcatechin). — This substance was 
found in the urine of a male child, four months old, by 
Ebstein and Mueller ; on addition of caustic potash solu- 
tion the urine darkened, especially on shaking ; an alka- 
line solution of copper was reduced on heating. It is 
possible, therefore, from these and other reasons, that 
Boedecker's "alkapton" was this substance. 

Uro-rubro-haematin and Uro-fusco-hsematin. — Baum- 
stark found these pathological coloring matters in the 
urine of a patient afflicted with leprosy. The quantity of 
the two pigments amounted in twelve days to about two 
grammes. The color of the urine was at first a deep, 
dark red like Bordeaux wine, gradually becoming brown- 
red and toward death a pure dark brown, almost black. 
Acetone, Alcohol, and Ethyldiacetic acid. — The chloro- 



APPENDIX. 189 

form odor of many diabetic urines is said to be due to the 
acetone which they contain ; such urines are colored dark 
reddish-brown with iron chloride. (Kussmaul affirmed 
that diabetic coma was due to acetone in the blood ; but 
in several cases competent observers have found none, and 
in others, only faint traces.) The substance in the urine 
of diabetics which gives a red coloration with ferric chlo- 
ride, resembles in this respect acetic ether ; it also breaks 
up into acetone and alcohol. Nevertheless, Quincke has 
shown that urine giving this reaction with ferric chloride 
does not smell of acetic ether, nor can the latter be extracted 
from the urine by shaking with ether, and, if in combina- 
tion, is neither with acids, alkalies or normal constituents. 
Deichmueller failed to obtain any alcohol from forty 
litres of diabetic urine, but found from .093 to .147 per 
cent of acetone. He concludes that the substance giving 
the red coloration with ferric chloride, is free diacetic 
acid. Tollens confirms this, and adds that when such 
diabetic urine is shaken with ether there is only a trace of 
the ferric chloride reaction with the ether extract ; but 
when a solution of ethvl-aceto-acetate was added to the 
urine in proper proportions, the latter was readily ex- 
tracted bv ether. 



RESULTS OF RECENT ANALYSES. 

One hundred specimens of urine recently sent from 
Chicago and various localities in Illinois, Wisconsin, Iowa, 
Michigan and Missouri, yielded, on analysis by the author, 
the following results : 

Total number of specimens, - - - - 100 

Containing Albumin, ----- 24 

iC Sugar, 10 



190 APPENDIX. 

Containing Biliary matters, - - - 2 

" A noticeable sediment, - 84 

Normal, or nearly so, 10 

Under the head of Albumin and Sugar are counted only 
such specimens as contained an appreciable amount of 
those constituents. 

Albumin. — Out of the twenty-four specimens' in which 
albumin was found, six were from patients suffering from 
well-recognized Bright's disease; three specimens con- 
tained albumin due to the presence of pus alone; two 
specimens contained albumin, due to blood alone The 
remaining specimens, thirteen in number, were, in nine 
cases, from patients suffering from acute febrile disorders, 
including pulmonary and cardiac troubles, and, in four 
cases, from those whose maladies — as far as the author 
could ascertain — were not definitely diagnosed. 

The highest specific gravity of any specimen of urine 
containing albumin, was 1035 ; the lowest, 1005. 

Sugar. — Of the ten specimens of urine containing sugar 
eight were from patients haying diabetes mellitus; the 
remainder, two in number, were from persons whose sub- 
sequent history could not be ascertained. 

Highest specific gravity of any specimen containing 
sugar, 1044 ; lowest, 1030. 

Sediments. — The constituents of the sediments in the 
eighty-four specimens which contained them in plainly 
visible amount, were various : Uric acid, urates, or both 
together, were found in twenty-eight specimens; phos- 
phates were detected in plentiful amount in seventeen; 
oxalate of calcium crystals weie seen with the microscope 
in abundance in ten; blood was found in six; pus in 
eight ; tube-casts in ten ; excess of mucus, epithelia, etc., 
in a large number ; it will be seen, therefore, that one 



APPENDIX. 191 

specimen of urine would often furnish a variety of differ- 
ent constituents in its sediment. 

It will be noticed that the most common deposit in 
these cases was that of urates ; this, I believe, is the case 
in general. 

It is said in some text-books that next to urates oxalate 
of lime is the most common urinary sediment ; I have not 
found this to be the case in specimens of urine I have 
seen thus far, the phosphatic sediment being more abund- 
ant than the oxalate, not only in the cases recorded 
here, but in many others which have come under my 
observation. 

Of the seventeen specimens containing sediments of 
phosphates, ammonio-magnesian phosphate was found in 
the freshly-voided urine of four patients. 

Remarks on the Specific Gravity of a Number of the 
Specimens. 

The specific gravity of seventy-one of the most inter- 
esting specimens being taken, showed that thirty-seven of 
them were 1030 or upward; nine were either 1025 or 
between 1025 and 1030; fifteen were either 1020 or 
between 1020 and 1025 ; three were 1015 or between 
1015 and 1020; six were 1010 or between 1010 and 
• 1015 ; two were below 1010, namely, 1007 and 1005. 

In other words, sixty-one out of the seventy-one were 
above 1020. 

Although the high specific gravity found in these 
cases could be accounted for largely from the nature of 
the complaints from which the patients were suffering, 
nevertheless, comparatively few specimens of twenty-four 
hours normal urine less than 1020 have come under the 
author's observation in this western climate. As to 
whether the normal range is really 1020 to 1030 in this 



192 APPENDIX. 

section of the country, or whether the prevalence of 
"malarial" fevers, or other conditions, is responsible for 
it. is a question. 

Of the nine specimens below 1020 in specific gravity 
seven contained albumin not due to pus or blood ; in four 
of the patients Bright's disease was the trouble, as to the 
other three the exact diagnosis has not been made with 
certainty. Of the four patients known positively to have 
Bright's disease, two have died, namely, those the specific 
gravity of whose twenty-four hours urine was 1007 and 
1010 respectively, at the time when examined by the 
author. 



GLOSSARY. 

Albuminuria. — Voiding of urine containing albumin ; 
this term is used by some authors to mean Bright's disease. 

Albuminoid Substances.— Those resembling albumin, as 
mucin, fibrin, etc. Protein substances. 

Baruria.— The passing of urine containing increased 
amount of solid matters only. 

Bilharzia Haematobia.— Name of a parisite sometimes 
found in the intestines, bladder, etc., of persons living in 
certain hot climates. 

"Brick-Dust" Sediments.— Those containing in large 

part uric acid or urates. 

Calculus.— Stone in the bladder. Calculi, plural of 

calculus. 

Chyluria. — Voiding of urine containing chyle. 

Diuresis. — Profuse discharge of urine. 

Diuretics. — Substances increasing the flow of urine. 

"Dry" Tests for Albumin, Etc.— Those in which the 
chemicals used are in the solid form. 



APPENDIX. 193 

Dysuria. — Painful, difficult voiding of the urine. 

Ecchinococcus Hominis. — Hydatids sometimes found in 
the urine from cysts formed in kidneys or vicinity of 
urinary apparatus. 

Enuresis. — Incontinence of urine. 

Extractive Matters. — Imperfectly defined substances 
pre-existing in the blood and occasionally found in the 
urine. 

Fermentation. — Decomposition of urine ; two kinds are 
recognized, namely, acid and alkaline. 

Glycosuria. — Voiding of urine containing sugar; the 
term is sometimes used by authors to mean diabetes 
mellitus. 

Glucose. — Sugar of grapes, etc; used to mean the 
sugar found in urine. 

Gravel. — Minute calculi. 

Hydruria. — Voiding of urine containing increased quan- 
tity of water only. 

Kiestein. — Name given to a "scum on the surface of 
urine during its putrefaction." Thought at one time to 
be of diagnostic significance in pregnancy. 

Lateritious. — An adjective used to describe "brick- 
dust" sediments and urine containing them. Thus, a 
lateritious sediment is a sediment looking like " brick* 
dust." Lateritious urine is that containing a -brick- 
dust" sediment. 

Leucocytes. — General term for white blood corpuscles,, 
mucus or pus corpuscles. 

Lithic Acid and Lithates. — Old terms for uric acid and 
urates. 

Lithaemia. — State of the system when uric acid is elim- 
inated in excess but usually with a diminution of the- 

tia 



194 APPENDIX. 

other urinary constituents ; the term is also used in gen- 
eral to describe a condition when uric acid is in excess in 

the urine. 

Lithuria. — Voiding of urine containing increased uric 

acid. 

Melanin. — Black pigmentary matter. 
Mucin. — The principal organic constituent of mucus. 
Mulberry Calculus. — One composed of oxalate of lime. 
Oxaluria. — Voiding of urine depositing oxalate of lime. 
Polyuria. — Voiding of urine containing increased water 

and solids. 

Xanthuria. — Voiding of urine depositing xanthin. 



« DRY " TESTS. 

The use of dry tests for urinary constituents is to be 
recommended on the score of convenience and neatness. 

The test for albumin already mentioned— that of tri- 
chloracetic acid, used by Eaabe — is very simple in its 
application. The acid is sold in the form of crystals ; 
drop one of these crystals into a test tube half full of the 
suspected urine and the test is performed — a cloudy zone 
forming (as the Grystal dissolves in the urine) if albumin 

be present. 

The essential constituents of Fehling's or Pavy*s solu- 
tions may be prepared in the dry form* and sugar tested 
for, in a manner almost as simple as the test above; 
moreover, when the substances used in testing for sugar 
are kept in the dry form and used only when needed, 
there is none of that deterioration which Fehling's solu- 
tion itself is liable to undergo. 

* Dr. Pavy, of England, suggested the use of pellets. 



APPENDIX. 195 

» 

Messrs Gross & Delbridge, of Chicago, prepare the tri- 
chloracetic acid, sulphate of copper, tartrate of potash, 
etc., for use in the dry tests for albumin and sugar in the 
manner recommended by Raabe and Pavy respectively ; 
the materials inclosed in vials are sold in a neat case con- 
taining also several test tubes. 



To perform the test for sugar or tablets, proceed 
as follows: Take one cone of caustic potash and two 
tablets of neutral tartrate of potash and dissolve them 
in one drachm of water; next take one tablet of cop- 
per sulphate and dissolve in one-half a drachm of water. 
Mix the two solutions, add them to one-half an ounce 
of urine and boil. The characteristic reddish-yellow pre- 
cipitate will appear if sugar be present. 



196 APPENDIX. 

FORM OF RECORDING URINARY ANALYSIS. 

(To be printed on letter paper.) 

EXAMINATION OP URINE. 

p or _ _. , at request of 

Dr 

PHYSICAL CHARACTERISTICS. 

Total quantity in twenty-four hours, 

Color and Appearance, 

Odor, 

Keaction, 

Specific Gravity, 

CONSTITUENTS. 

Albumin, 
. Bile, 
Sugar, 
Normal Constituents. 

DEPOSIT. 

Quantity and Appearance, 
Chemical Constituents, 
Microscopical Constituents. 

CLINICAL REMARKS, ETC. 



(Signed), M - D - 



Index 



INDEX. 



Preface 3 

Introduction 5 

Metric System 23 

Part I. 

Practical Urinalysis 24 

Par? II. 

Clinical Significance 81 

Appendix. 

Calculi -69 

Effect of Reagents 17 2 

Changes on Standing 173 

Vhat to Look for in Urine of Disease 173 

Micro-Chemical Summaries 178, 179 

Fare Constituents 181 

Results of Analysis 189 

Glossary 192 

"Dry" Tests 194 

Form of Recording Unnary Analysis 19 



Abnormal Constituents 33 

Lrine 93 to no 

Ace:ic Acid 12, 33, 186 

Acetone 188 

Acii Fermentation 106 

Acid Phosphate of Sodium 

amount in normal urine 81 

Acids 12, 13 

Accidental Coloring' Matters 102 

Acute Yellow Atrophy of Liver 115, 125 

what to look for in 174 

Addison's Disease, urea in 115 

Adjustment 18 

Air-Bubbles 

to remove from urine 27 

in urine of albuminuria 105 

containing bile 105 

containing sugar 105 

Albumin, tests for 33 to 35 

significance of. 41, 129 to 138 

and sugar together 40, 42 

" normal" 129 

transitory 130 

diet, etc , affecting 130 

diseases in which found 130 

drugs affecting 131 

Albuminuria 

in diphtheria . 132 

in pregnancy 132 

in Bright's disease 132 133 

what to look for in 173 

Alcohol 12, 188 

Alkalies 13 

Alkaline Fermentation 106 



Alkalinity of the Urine 

significance of 32, 106-109 

artificial production of. 107 

produced by diseases 107-108 

due to fixed alkali 108 

to volatile alkali 109 

cautkns in regard to 109 

contents of. 108 

Alkapton 184 

Allantoin 186 

Alloxan 186 

Allen's Sugar Test 38 

Aloes 103 

Ammonia 12, 18, 109, 182 

Ammonium Carbonate 108 

molybdate 12 

Ammonium urate 147, 170 

Ammoniacal Urine 106, 109, 116 

Ammonium Salts 182 

Ammonio-Magnesian (or triple 

phosphate) 144 

microscopic appearance of. 48, 49 

as Calculi 80, 171 

significance of. 144 

Amyloid Degeneration, 73, 95, 97, 158 

casts 65 

Anaemia 3 1 * 79» io 7 

Analysis by Author 189 

Aniline 97. I0 3 

Antidotes 14 

Apparatus 

chemical 1-12 

microscopical i5 _I 7 

Appearance of the Urine 25 



200 



INDEX. 



significance of 31 

Asparagus 106, 148 

Arthritis 123, 175, 177 

Ascites ,31, 32, 98, 100, 101, 116 

Asthma 114 

Author's Analyses 189 

observations on quantity of urine 

in twenty-four hours 82 

Average composition of normal 

urine 81 

Average number of urinations daily 90 
Average of quantity voided at each 

urination 90 

Average quantity urina sanguinis... 90 

Bacteria 71, 74, 167 

Baldrianic Acid 186 

Barium Chloride 12, 77, 172 

Benzoic Acid 186 

Biliary Acids 142, 185 

Bile 41, 42, 142, 174 

Bird's Tables 28 

Bladder Affections (see Cystitis). 

Blood 159-163 

clinical significance 71, 159-163 

tests 52 

microscopic appearance 53-56 

coloring matters 71 

diseases in which found in urine 160 

Blood extractives 35 

Blue Urine 104 

Boil, how to 6, 35 

Bone Diseases 122, 123, 124, 152 

what to look for in 176 

Brenzcatechin 184, 188 

Bright's Disease 

quantity of urine in, 31, 95, 97, 133 
to 138 

albumin in 41 

blood in 71 

casts in 73 

urea in 79, 115 

specific gravity of urine in 98 

sulphates in 121 

phosphates in 122 

"diagnosed" from urate sedi- 
ments 145 

mucus in 155 

Bumping, prevention of. 37 

Burns, Effect of on Urine 103, 123 

Butyric Acid 186 

Calcium 

oxalate 148 

phosphate 144 

Calculi 51 

examination of. 79, 169-172 

uric acid 80, 170 

phosphatic 80, 170 

oxalate.... 80, 170 

carbonate of lime 80 

Calculation 

of specific gravity 28 

of solids 29 

Camel's hair pencil 71 

Campeachy wood 103 

Cancer 79, 123, 125 

Cancer cells 166 

Carbolic Acid 181 

Care of microscope 18-20 



Carmine solutions 21 

Caries 123 

Casts 

amyloid 65 

blood 63 

classification 157 

clinical significance 73, 156 

collection and examination 63 

epithelial 63 

fatty or oil 63 

fibrinous 63 

granular 63 

hyaline, waxy 64 

mucus 66 

origin of..... J156 

white cell 158 

of seminal tubules 67 

how to identify 6j 

cautions 67 



diseases in which found 156 

in Bright's disease J 157 

Cells j 15 

Cerebral troubles.. 121, 123 141 

Cerebro-spinal diseases 96; 123 

Cerevisiae (see Torula). 

Chemical terms 12 

Chemicals, use of. ,....i 12 

Chlorides 

amount of in normal urine 81 

chlorinated soda 12 

chlorine 18 

significance of sodium chloride... 119 

Chlorosis 31, 79, 107,114 

what to look for in 1:75 

Cholestearin as calculi 169, 1 85 

Cholera 

quantity of urine in 96 

urea in 114 

chlorides in 119 

phosphates in 122 

Changes in normal urine on stand- 
ing 173 

Chylous urine '••49> 5 2 > io 55 JS 1 

Circumstances 

increasing quantity of urine 85 

decreasing " " " 85 

increasing solids in urine 91) 

decreasing " " " 91 

affecting color of urine 105 

Clinical cases, urine in 99, 100 

Clinical Summaries 

physical characteristics 31 

abnormal constituents 41 

non-organized deposits 50 

organized deposits 71 

normal constituents 79 

Clinical significance of urine 81-167 

Cirrhosis of liver 31, 97, 125 

Cold, exposure to 159 

Collection of sediment 8, 10 

Coloring matters 183 

amount of in normal urine 81 

significance of. 127 

Convalescence 31 

Cover 

glasses 17 

pasteboard 17 

Color of urate sediments 146 



INDEX. 



201 



Color of the urine 25, 31, 101-104 

abnormal 31 

accidental 31 

normal 25, 31 

significance of. 31, 101-104 

colorless urine 101 

high-colored 102 

blood-red 102 

dark brown 102 

green 102 

dirty-blue 102 

smoky 102 

white 102, 105 

black 102 

pale 102 

milky 102 

Composition of the urine 81 

Condensed yeast 12 

Consistency of the urine 105 

Convulsions 31 

Creatin and Creatinin 

amount in normal urine 81, 128 

significance of. 128, 181 

Copaiva 34 

Cubebs 34 

Cystin 

as calculi 187 

clinical significance 187 

general appearance of deposit 187 

microscopic appearance 187 

tests for 187 

Cystitis 

odor of urine in 106 

reaction of urine in 108 

false albuminuria in 133 

Damaluric Acid 182 

Damolic Acid 182 

Debility 107 

Declat Method 121 

Decreased Quantity of Urine 31, 96 

Deposits 

apparatus for collection of.. ...8, 10, 18 

classifications 42, 142 

due to natural causes 144, 145, 148 

examination of. 18, 21, 22 

micro-chemical analysis 178, 179 

non-organized 43, 143, 178 

organized 52, 143 179 

phosphatic 143, 144 

urate 145 

uric acid ~ 147 

oxalate -. 150 

Diabetes 31, 79, 95, 99, 124 

insipidus 95 

what to look fo 1 in 174 

mellitus 95, 139 

what to look for in 176 

quantity of urine in 94 

specific gravity in 99 

odor 106 

urea in 112, 114 

phosphates in 123 

Diabetic Food 140 

sugar 138 

urine 106, 140, 189 

Diet 

affecting odor of urine 106 

quantity 95 



affecting urea in 

chlorides 119 

" uric acid 125 

Differential Density 

fermentation test 39 

Diffuse Bronchial Catarrh 112 

Diphtheria 41 

Diseases 
affecting quantity of urine, 31,94-97 

color of urine 31, 102 

u odor of urine 31,106 

aspect of urine 31, 104 

reaction of urine 32, 107 

specific gravity 32 

solids 3? 

" consistency 105 

urea 112, 114 

chlorides 119 

phosphates ■. 122 

uric acid 125 

causing presence of albumin 130 

deposits, 144, 145, 147, 

^. .„ J 49> I 53, I 55, 156, 160, 164 

Distilled water 12, 17 

Diuretics 97 

Drop bottles 21 

Drugs. 

affecting quantity of urine 97 

" color 102-104 

odor 106 

reaction 107 

solids 109 

fluid no 

urea 112 

" chlorides 119 

" phosphates 122 

hippuric acid 128 

uric acid 125 

" albumin 131 

" deposits 143, 149 

" presence of fat 151 

" " of casts 156 

causing oil in the urine 152 

"Dry" Tests 192, 194 

Dyspepsia 107, 147 

Dysuria 193 

Effects of Reagents on Normal 

Urine 172 

Enteric Troubles 107, 123 

Epithelium. 

recognition of 60, 155 

significance of. 72, 155 

diseases in which abundant 155 

Extractive Matters 42 

Extraneous Substances 67 

Eye-glass 15 

diseases 124 

Estimations . 

quantity of albumen 34 

" " sugar. 39 

"' " urea 75, 116 

'• " chlorides 76 

" " phosphates 77 

" " uric acid 126 

" coloring matter 128 

Exacerbations. 

febrile 146 

Exanthemata, urea in , 112 



202 



INDEX. 



Experiments of Author 82 

Fat. 

detection of. 49 

significance of. 51, 151 

Form for Recording Urinary Ex- 
aminations 196 

Formic Acid 186 

Froth on Urine - 105 

Fungi. 

microscopical appearance of 69 

significance 73, 167 

Fehling's Solution 12 

Fevers, etc 31, 79 

quantity of urine in 96 

specific gravity of urine in 99 

solids in 101 

cerebro-spinal 96 

intermittent 96, 113, 120 

typhoid. 113 

typhus 7T, 73, 96, 113 

yellow 96, 114 

what to look for in 174 

Filtration 9 

Fibrinuria 105, 183 

Glass. 

covers.....*.... 17 

jars 11 

rods 11 

slides 15 

Glossary 192 

Glycosuria 138, 141 

Gonorrhoea 72, 153 

Gout. 

atonic 31 

urea in 114 

phosphates in 123 

uric acid in 148 

what to look for in 177 

Gramme 23 

Gravel 51 

Guaiac... 52 

Hsematuria 159 

Haemoglobinuria 158 

Haines* Sugar Test 36 

Heal, how to 6 

Highly Colored Urine 31 

Hints to Diagnosis 

of Bright's disease 138 

of uric acid calculus 148 

from blood in the urine 160-163 

from pus ...164 

from spermatozoa 165 

of calculi 171 

HippuricAcid 128 

Hydrochloric Acid 12, 13, 18 

Hydrogen Peroxide 183 

Hydruria 94 

Hysteria 31 

temporary increase of urine in.... 95 

what to look for in 176 

Hypobromite Process for Urea 116 

Hypoxanthin 181 

Hyposulphurous acid 182 

Irritation 153 

Iron 182 

Indican 

test for 78 

significance 79 



Icterus 

what to look for in 174 

Infants' urine 

odor of. 93 

Inflammation 

with exudation 79, 119 

urea in 112 

chlorides 119 

phosphates 122 

what to look for in 174 

Infusoria (See Fungi )♦ 

Increased Quantity of Urine 31, 94 

Increased Tension 95 

Inorganic Constituents of the Urine 81 

Inosite 185 

Intermittents 

what to look for in 177 

quantity of urine in 96 

urea in 113 

chlorides in 120 

phosphates in 123 

Interstitial Nephritis 

quantity of urine in 95 

Lactic Acid 186 

Lactose 185 

Lardaceous Degeneration 158 

Lens 15 

Leucin 187 

Leucorrhcea 72, 155 

Leukaemia 177 

Linen, old 17, 19 

Lithaemia 125 

Litmus Paper 11 

Litre 23 

Liver, Diseases of 

reaction of urine in 107 

acute yellow atrophy of. 115, 125 

cirrhosis 31, 97, 125 

cancer 125 

oxaluria in 149 

uric acid in 146 

what to look for in 177 

Lung Diseases 

what to look for in 175 

Metric System 23 

Micro-Chemical Examinations, 178, 179 

reagents 21 

summary 178, 179 

Microscope.... 15 

Magnesium 

ammonio-phosphate 144 

Magnifying Powers 15 

Masturbation 73 

Meals 

effect on urine 91, 93 

Meningitis 123 

what to look for in 175 

Menstruation . 71 

Mirror 18 

Mollities Ossium 123 

Mould Fungus 167 

Movement 18 

Mucin 60 

Mucus 

recognition of. 59 

tests for .—59> x 53 

microscopical appearance of, 59, 153 
significance of. 72, 153 



INDEX. 



203 



amount of normal urine 81 

differentiation from pus 153 

diseases in which abundant 153 

Nephritis 

interstitial 95 

scarlatinal 96 

acute parenchymatous 97 

chronic " 97 

glomerulo-nephritis 158 

Nephro-zymase 184 

Nervous diseases 79 

urea in k 112, 114 

phosphates 122, 123 

what to look for in 176 

Nitric Acid n, 13, 18 183 

Nitrogen 114, 118 

Nitrogenous food in, 114, 125 

equilibrium 126 

Nitrous Acid 183 

Normal Constituents 74 

testS'forurea 74 

" " chlorides 76 

" " phosphates 77 

" " sulphates 77 

" " urates 78 

" " coloring matters 78 

" "mucus 78 

" " creatinin and hippuric 

acid 79 

clinical significance of. 110-129 

Normal Urine 81-93 

Nubecula 92 

Number of Urinations Daily 86-90 

Objective 15 

Odor of Urine 26 

how modified 106 

significance of. 31, 106 

Oil in Urine 152 

Organic Constituents of Urine 81 

Ovarian Tumor 114 

Oxalate of Lime 

clinical significance of. 51, 148 

general appearance of deposit... 45 

microscopical appearance of. 47 

deposit due to physiological 

causes 148 

deposit due to pathological causes 149 

Oxalic Acid 148 

Oxaluria 51, 149 

Oxaluric Acid. 181 

Oxymandel Acid 188 

Oxyphenic Acid 188 

Pale Urine 31 

Paralbumin and Paraglobulin.. 183 

Paralysis 114, 144 

Penicilium Glaucum 70, 167 

Peptone 184 

Peritonitis 

what to look for in 175 

Phosphates 
clinical significance of, 51, 79, 122-124 

tests for the 47 

amount of, in normal urine 81 

deposits of. 144 

Phosphate of Lime, amorphous 47, 

*23> 144 

crystalline 144 

microscopic appearances 48 



Phosphaturia 124 

Phthisis 79, 107 

Polyuria j 94 

Physical Characteristics of the 

Urine 24-32, 93-110 

Pigments of the Urine 

affinity for uric acid 44 

and urate sediments 44 

Pipettes 8- 

Potassa 12 

Pneumonia 79, 113, 120, 107, 123 

Poisoning, Effect of on Urine 

by mineral salts 97, 131, 159 

potassium chlorate 97, 103 

pyrogallic acid 97, 103 

aniline compounds 97, 103 

atropine 97 

phosporus 151, 97, 113, 159, 121, 

122, 131, 142 

cantharides 97 

arsenic 97 

carbolic acid 97, 103, 121, 131, 151 

ergot 97 

iodine 97, 131 

mercury ...... 97 

opium 97 

chronic lead 97, 101, 104, 159 

duboisin 103 

arseniuretted hydrogen 131, 159 

carbon protoxide 131, 151 

" dioxide 131, 159 

potassium iodide 131 

turpentine 152 

hydrocyanic acid 159 

Potassium 

caustic potash 12 

ferro-cyanide 12 

Powers 16 

Precipitate * 14 

Practical Urinalysis 23-80 

Pregnancy 41 

Progressive Muscular Atrophy 120, 

,121, 123 



Pus in the Urine 56 

occurrence and recognition of..... 56 

clinical significance of. 71, 164 

microscopical appearances of. 58 

effect on consistency of the urine 105 

diseases in which found 164 

Pyaemia 114 

Pyuria 164 

Pyorrhoea 73 

Quantity of the Urine 24, 31, 81-86 

modified by cutaneous exhalations 85 

" diseases 93~97 

" drink 85 

" food 85 

" pulm'ary exhalations 85 

" sex and age 85 

" sleep 85 

" stools 97 

significance of. 31 

in Bright's disease.... 31, 94,95* 97 

diabetes 
Quantity of Urine Passed at Dif- 
ferent Periods 86 

Quantity of Urea in 

chlorides 119 



tt 



tt 



ft 
tt 



ft 



204 



INDEX. 



Reaction of the Urine 26 

modified by diseases 107 

" •« food 32 

" " medicines 107 

" standing 107 

significance of. 32, 107-110 

tests for 26 

Reagents 

chemical 11-12 

microscopical 21 

Rachitis 122 

Rheumatism 

quantity of urine in 94, 96, 120 

what to look for in 175, 177 

Sodium 

chlorinated soda 12 

chloride 76, 79, 119 

Solids 29-31 

amount in normal urine 81 

how to calculate 30, 91 

significance of. 100 

Specific Gravity 26-29 

significance of. 32, 98 

Spermatorrhoea 73 

Spermatozoa 

microscopical appearance of. 68 

significance of. 73, 165 

Spirits Turpentine 12 

Spinal Diseases 

blue urine in 104 

what to look for in 176 

Salts 14 

effect of on urine 97 

Sandal Wood 34 

Sediment (See Deposit). 

Sarcinae 70, 73 

Silicic Acid 182 

Silver Nitrate 12 

Scarlet Fever 107 

Scurvy 71, 125, 177 

Skin Diseases 

sugar in 147 

what to look for in 177 

Stage , 15 

Stains 13 

Succinic Acid 181 

Sugar, in the Urine 

tests for 35, 09 

" " quantity 39 

significance of. 41, 138, 141 

diet causing 138 

diseases where found 138 

drugs affecting 139 

Sugar and Albumin 

alternating with uric acid 147 

in skin diseases 147 

together 40 

significance of. 42, 141 

Sulphuric Acid 12, 13 

clinical significance of. 121 

Sulphates 

test for 77 

significance of 79 

amount of in normal urine 81 

Sulphuretted Hydrogen 18, 186 

Syphilis 123 

Tests for 

abnormal substances 33 to 41 



albumin 

alkaline phosphates 77 

amorphous urates 43 

bile acids 185 

bile pigments 41 

blood ." 52 

blood coloring matters 159 

coloring matters 78 

chlorides 76 

chyle 49 

creatinin 79 

cystin 187 

deficiency of urea 74 

earthy phosphates 77 

excess of urea 74 

leucin 188 

mucus 59, 78, 153 

oxalate of lime 46 

pus 50 

'sugar 35, 39 

sulphates 77 

tyrosin...... 188 

urates 78 

urea 75 

uric acid *. 44 

Test Glasses 7 

Test-Tubes 5 

tube rack 5 

" brush 5 

Torula Cerevisiae 70, 167 

Transparence of Urine 106 

Trapp's Coefficient..... 91 

Trichloracetic Acid 12 

Turpentine 12, 34 

Typhus 71, 73 

quantity of urine in 96 

blue urine in 104 

reaction in 107 

hemoglobinuria in 159 

Tyrosin 187 

Urates 

significance of 79, 124 

amorphous 140 

amorphous, test for 43 

crystalline 146 

precipitated by acid fermentation 50 

by cold 50 

by pathological conditions, 50, 51, 

125, 145 

by physiological conditions, 50, 145 

. microscopical appearances of.. .43, 44 

amount of in normal urine 81 

deposits 145 

color of. 146 

Urate of Ammonium 124 

of calcium 124 

of magnesium 124 

of potassium 124 

of sodium 43, 124 

Uraemia 100, in 

Urea 

decomposition of. 108 

significance of. 79, 112, 115 

modified by diet in 

" " disease 112 

nitrate of. 74 

quantitative test for 75, 116 

test for deficiency of. 74 



INDEX. 



205 



test for excess of. 74 

amount in normal urine 81 

tables of Harley in 

influence of age upon in 

excretion of in 

Uterine Diseases 

cancer 114 

Uric Acid 

clinical significance of. 50, 125 

colored by pigments 45 

common forms of. 45 

general appearance of deposit.... .44 
microscopical appearance of.. ...44, 46 

test for 44 

rare forms of. 46 

solubility of. 44 

amount of free in normal urine... 81 

calculi 80, 170 

deposits of. 147 

estimation of. 126 

Urina Cibi 86 

potus 31, 86 

sanguinis 86 

Urohaematin 

test for 78 

significance 79 

Uro-rubro-haematin 188 

Uro-fusco-haematin 188 

Urine 

acidity of. 26, 107 

acid fermentation ... 106 

alkalinity 26, 108 

apparatus for collecting 134 

pale 102 



black 102 

blue 102, 104 

quantity of normal 82 to 90 

color of normal 81, 92 

consistency of normal 92, 104 

reaction of normal 93 

extraneous substances in 67 

specific gravity of normal 91 

fluorescence of normal 92 

glass for deposits 6 

turbidity 104 

green 102, 103 

odor of normal 93 

opacity of. 104 

when to examine 25 

solids in normal 91 

transparence of normal 92 

transparence of abnormal 104 

of infants 93 

Vibriones 71, 74 

Valerianic Acid 186 

Volatile Fatty Acid 186 

Water, distilled 12, 17 

amount in urine 81 

What to Look for in Urine' of Dis- 
ease 173 

Window Suitable for Microscopic 

Work 17 

Xanthin 181 

Yeast 

condensed 12, 13 

fungus 167 

Yvon's Process for Urea 116 



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18 8 2. 



</ 



GROSS & DELBR1DGE S Publications. 



The Science and Art of Obstetrics. By Sheldon 
Leavitt, M. D., Prof, of Obstetrics and Clinical Mid- 
wifery in Hahnemann Medical College and Hospital, Chi- 
cago; author of "The Therapeutics of Obstetrics," etc. 
658 pages, royal octavo. Price, cloth, $6.00; sheep, $7.00. 
265 illustrations. 

This work is intended to fill the want so long felt by Homoeo- 
pathic teachers of Obstetrics, students, and practitioners, ot a 
text book which should deal with the subject as both a science 
and art, and embody the researches and improvements which 
have been made in this branch of medicine during the past tew 
years. The work has been carefully prepared, and sets m the 
foreground no theories or empty chimeras in respect to etiology, 
pathology, diagnosis, or treatment, but accepted ideas, ana 
rational deductions from extensive observations and experience. 

"We are in receipt of advance sheets, covering nearly one-half the text of 
this forthcoming book, which promises to be a text book par excellence, as 
the matter appears to be concisely prepared and quite free from the theory 
and qnotation which so often form the bulk of similar works. In other 
words, we may say that it is the vade mecum of the department which it 
represents, and compares favorably with a similar work prepared by Prof. 
T. G. Thomas, for the use of his students. 

A marked feature of the book is its divisions and sub-divisions, by means 
of which the student will the more readily grasp and complete the study of 
each particular subject before entering upon another. This we consider an 
important point in a book of this character. 

The illustrations embrace some two hundred and fifty figures of excellent 
design and execution; many of them are original, and some are drawn from 
life. These drawings are of inestimable value to the stndent of midwifery. 

The aim of the author has evidently been to present a clear, dignified and 
creditable treatise on the subject, and as far as we have examined, all im- 
portant points seem to have been touched upon and the practical ones suf- 
ficiently elaborated. 

The physical part of the work, so far as we can judge, will be faultless, as 
might be expected, the name of the publishers being sufficient guarantee in 

this particular. .., 

This work must certainly become the text-book of our colleges, and it will 
be found an excellent hand-book for the busy practitioner, because every 
important point of obstetric practice is so clearly stated, and from the 
arrangement, so readily found. 

We congratulate the author on the success of his effort, the publishers on 
their opportunity to issue so worthy a book, and 'Our School' on possessing 
the ability within itself which has made such an undertaking possible. -JXew 
York Medical Times. 

GROSS & DELBMDGE, Publishers, 

4,8 Madison St., CHICAGO. 



GROSS & DELBRIDGE'S PUBLICATIONS. 



A Physiological Materia Medica, containing all that is 
known of the Physiological Action of ouf Remedies, their 
Characteristic Indications, and their Pharmacology By W, 
H. Burt, M. D. Chicago : Gross & Delbridge. 1881. 992 
pages. Cloth, $7, Sheep, $8. Third edition. For sale by 
Homoeopathic Pharmacies, or sent free by the Publishers, on 
receipt of price. 

We believe that no book on Materia Medica in our literature 
so completely meets the requirements of the Physician and Stu- 
dent as this; and, as proof of the correctness of this opinion, we 
have to announce the sale of the entire first edition in ninety 
days. Such a reception has never been awarded before to any 
book in Homoeopathic literature The demand for the work in- 
dicates that its appearance was opportune, and that its plan and 
execution are approved by the Profession We have received a 
large number of favorable notices botn from Physicians and the 
Press, from which we make the following selections : 

Dr. Burt has brought together in a compact and well arranged 
form an immense amount of information The profession will 
fully appreciate the labor and skill with which the author ha* 
presented the physiological and pathological action of each druo- 
on the organism.— New York Medical Times. 

We are sure that Dr. Burt's new work will have deservedlv a 
rapid sale. Gross & Delbridge are a new publishing house in the 
medical line ; but certainly they must be old hands in the busi 
ness. for paper and printing leave nothing to be desired. May 
they never falter m such laudible work, and the eyes of the read 

ll7Z^%lZ P X ei - Br - Lilienthal in 2Wi *- £l 

EJXir b6St b00k - mak - of our time.-*, Louis 

J^^S^^MS^ 1 interesting and profit - 

o&MSSaJsr of Bifting tlie tares from the wheat - 

JlSteofSSS. reCOmmend Dr - Burt ' s book.-*- England 
The work is a credit to Chicago— Medical Investigator. 

GROSS & DJELBKIDGE, Publishers, 

48 Madison St., CHICAGO. 



GROSS & DELBRIDGE'S PUBLICATIONS. 



A Complete Minor Surgery. The Physician's Vade-me- 
cum. Including a Treatise on Venereal Diseases. Just 
published. By E. C. Franklin, M. D., Professor of Sur- 
gery in the University of Michigan. Author of "Science 
and Art of Surgery," etc. Illustrated with 260 wood cuts. 
423 pps. Octavo. Price, cloth, $4.00. Sheep, $4.50. 

This work is just such a one as might be expected from the 
rjen of one experienced in teaching as our veteran author, and 
is properly designated as "complete." The text is lucidly and 
concisely written, the therapeutics clear and practical, and the 
whole is well adapted to the uses of the general practitioner. 
This book fills a gap which has never before .been met, and we 
prognosticate a large demand foTit.-Mw York Medical Times. 

Prof Franklin has given us a work containing some new fea- 
tures, and embracing a larger field than has ^? t0 2%^^J' A 
ered by manuals of minor surgery. The work is well illustrated 
and is every way a most convenient and satisfactory treatise.— 
Chicago Medical Times (Eclectic.) 

This is a work containing all the general practitioner of medi- 
cine should endeavor to aisimilate on the subject of surgery. 
For ready references and emergencies this work is not surpassed . 
We heartily recommend the work to the profession. The pub- 
lishers have done good work in issuing the book so creditably, 
ind the SS will appreciate the large, distinct type used, 
and the prominence given words so as to enable the reader to 
fecure?eSduTthat which he is looking for. -Cincinnati Medical 
Advance. 

1 have been very much pleased in the perusal of Franklin's 
TViiVm Snifferv issued by your house. The book I have no 
doubt improve usef hi /o Che busy practitioner and add to the 
reputation of the learned author.-^-. Charles Adams. 

■nruu tv,; hnnV in nossession no practitioner will need any 
otS text boS on Minor Surgery. It is full and complete and 
2™ "hSw dressing and instrument known or used is illus- 
tZed-Br Valmtine in Clinical Review (St. Louis. ) 

For Sale at all the Pharmacies, or sent free on receipt of price. 

GROSS & DELBRIDGE, Publishers, 

48 Madison St., CHICAGO. 



GROSS & DELBRIDGES PUBLICATIONS. 



Lectures on Clinical Medicine. By M. Le Dk. P. 

Jousset, Physician to the Hospital Saint- Jacques, of Paris; 
Professor of Pathology and Clinical Medicine; Editor of 
L'Art Medical. Translated with copious Notes and Addi- 
tions by R Ludlam. M. D., Professor of the Medical and 
Surgical Diseases of Women and Clinical Midwifery in the 
Hahnemann Medical College and Hospital of Chicago. 
Large 8vo. of over 500 pages, cloth, $4.50; half morocco, 
£5.00. 

This work is one of very great interest to the profession and 
to students, embodying, as it does, about forty years of experi- 
ence on the part of the author, and that of nearly thirty years 
by the translator. It sets forth the best and freshest pathologi- 
cal views; the most practical application of the homoeopathic 
method of treating a disease; and a clear and forcible bed-side 
analysis of the cases that are presented. The author discusses, 
from a practical standpoint, the questions of Alternation, Atten- 
uation, Dose and Repetition, and of Individualization and 
Aggravation. The subjects embraced in these lectures include 
Asthma, Emphysema, Rheumatic Endocarditis, Articular Rheu- 
matism, Bronchitis, Pneumonia, Croup, Diphtheria, Typhoid 
Fever, Nephritis, Albuminuria, Haemoptysis, Haemorrhoids, 
Chronic Gastritis, Scrofulous Ophthalmia, Hydrarthrosis, Pelvi- 
peritonitis, Vaginismus, Menorrhagia, etc. 

The practitioner may here find cases analogous to puzzlers 
which occur in his own practice, and cannot fail to be benefited 
b}^ their perusal. 

"The work presents the latest pathological data, the most 
practical method of treating disease honioeopathically, and a 
critical analysis of each case related. It is eminentlv practical 
and demands the use of well proved remedies.''— From the Hah- 
nemannian Monthly, Philadelphia. 

It contains the very best and most reliable clinical experience 
in the practice of homoeopathy of any work extant in the pro- 
fession.—^. E. Small, M. L. t in the Chicago Tribune. 

I have carefully read the work and hardly know whether I 
admire more the plain thorough pathology and diagnosis, or the 
practical common sense, honest treatment set forth. * * The 
Notes of Dr. Ludlam are in keeping with our best American 
authorship.— J. P. Lake, M. L., Nashville, Tenn. 

The book is of great value to practitioners and students of 
medicine.— J. W. Lowling, M. L., Lean of the Neic York Homoeo- 
pathic Medical College. 

I have read the work with a good deal of interest and find it 
to be eminently practical and of great value to the profession.— 
T. O. Comstock, M. L. y St. Louis, Mo. 

GROSS & DELBRIDGE, Publishers, 

48 Madison Street, CHICAGO. 



GROSS & DELBRIDGE'S PUBLICATIONS. 



An Index of Comparative Therapeutics, with a pro 
nouncinff Dose-List in the genitive case,— a Homo-opathic 
Dose-List —Tables of Differential Diagnosis, Weights and 
Measures,— Memoranda concerning Clinical Thermometry, 
Incompatibility of Medicines, Ethics, Obstetrics, Poisons, 
Anaesthetics, Urinary Examinations, Homoeopath iiq Pharma- 
cology and Nomenclature, etc. By Samuel O. L. Potter, 
A. M M. D., late president of the Milwaukee Academy of 
Medicine, author of "The Logical Basis of the High Pottency 
Question," "Munchausen Microscopy, etc." Second edition. 
Price, cloth, $2.00-; flexible morocco, tuck, $2.50. 

The leading feature of this book is its comparative tabular ar- 
rangement of the therapeutics of the two great medical schools, 
Under each disease are placed in parallel columns the remedies 
recommended by the most eminent and liberal teachers in both 
branches of the profession. By a simple arrangement of the 
type used, there are shown by a glance the remedies used by 
both schools, as well as the remedies peculiar to each, for any 
given morbid condition. Over forty prominent teachers are re- 
ferred to, besides occasional references to more than thirty 
others. In the first class are Bartholow, Ringer, Phillips, Piffard, 
Trousseau, and Waring of the old School; Hempel, Hughes, 
Hale, Ruddock and Jousset among modern homoeopathic author- 
ities. 

"Dr Potter's compilation must be the result of a large amount 
of pains taking and accurate work, and will be appreciated. 
As an index it is very elaborate and serviceable."— Mew ting- 
land Medical Gazette. 

"The work is really a multum in parvo; as an index it is ex- 
haustive, and very often it supplies in a few words the very 
information that is wanted."— British Journal of Hommopathy. 

"I am much pleased with your Index. It is strong and will 
find sale among old as well as new school men/ Dr. J. r. 
Bake, Nashville, Tenn. 

"It will furnish the busy practitioner with a summary of im- 
mense practical value/'— Br. H. M. Paine, Albany, M. T. 

"It will be held in high appreciation by a large class of prac- 
titioners." Br. C. P. Hart, Wyoming, 0. 

"I like the idea very much; besides giving many valuable 
bints to the practical physician, it is very interesting from a 
theoretical point of view."— Br. H. C Clapp, Boston, 

For sale at the Pharmacies, or sent free on receipt of price. 
Price, in cloth, $2.00 ; in flexible morocco, tuck, £2.50. 

GROSS & DELBRIDG13, Publishers, 

4<* Madison St., CHICAGO. 



GROSS & DELBRIDGE'S PUBLICATIONS. 



How to Feed the Sick ; or, Diet in Disease. By 

Charles Gatchell, M. D., 2d. edition, revised and 
Enlarged. Price $1.00. 

This work is a very practical and timely volume not only for 
those who are sick, but also for those who are not really well, 
and to whom the problem, ''What shall I eat," is of vital impor- 
tance. As introductory, the various forms of animal, vegetable 
and inorganic foods are considered and their relative merits 
carefully pointed out. The Chapters that follow are devoted to 
such practical subjects as How to feed your Patients, Diet for 
Dyspepsia with aids to Digestion, Diet for Constipation, Rectal 
Alimentation, etc.; Diet in Consumption, Diet in Diabetis, 
Bright's Disease, Gravel; How to nurse the Baby, How to 
choose a Wet Nurse, How to wean the Babv, How to feed the 
Baby, Diet for Chloera Infantum, Diet for Travelers, Seasick- 
ness, the Corpulent, Scrofula, Rickets, Scurvy, Chlorosis, Col- 
lapse, Rheumatism, Asthma, Heart Disease, Alcoholism, Diar- 
rhoea, Dysentery, Cholera, Diphtheria, Gastritis, Biliousness, etc. 
Diet for convalescents is a valuable chapter. Then follows a 
long and carefully prepared list of recipes for the preparation 
of Beverages, Meats, Broths, Soups, Breads, Gruels, etc., etc. 

Milwaukee, Wis. 
"I consider your work on "How to Feed the Sick" to be the 
most practical, and therefore the most useful, work on the 
subject with which I am acquainted. No physician should be 
without it ; every mother should have it. It is in use in many 
of the households in which I practice/' C. C. Olmsted, M. D. 

"This work is plain, practical and valuable. It is really a 
clinical guide on diet, and one the profession will find reliable 
and correct. "—United States Medical Investigator. 

"Evidently much investigation, thought and carefulness have 
entered into the production of this work, and we believe it to 
be worthy a place in every household/'— The Magnet. 

* * * "We have carefully examined the work and shall 
cheerfully recommend it for family use. The directions as to 
what food and drinks, and modes of preparation are very 
judicious." * * * * * Resp. Yours, 

Janesville, Wis. Dr. G. W. Chittenden & Son. 

Milwaukee, Wis., Sept. 8, 1880. 
"Professor Gatchell's "How to Feed the Sick" is the best book 
on the subject for the people. It contains in 160 pages an 
astonishing amount of condensed information on a subject of 
great importance, and one but little understood. Its style is 
admirable, pithy and to the point. The book has no padding 
about it, and deserves an immense sale. Sam'l Potter, M. D. 

GROSS & DELBRIDGE Publishers, 

48 Madison St. 3 CHICAGO. 



GROSS & DELBRIDGE'S Publications. 



Antiseptic Medication, or Declat's Method. By 

Nicho. Francis Cooke, M. D., LL. D. Emeritus Professor 
of Theory and Practice in the Hahnemann Medical College 
and Hospital of Chicago. 128 pp. 12 mo., cloth, 1882. 
Price, $1.00. Gross & Delbridge, Chicago, Publishers. 

This is the first, and must continue to be for some time, the 
only treatise on this vitally important subject in the English 
language. It is plain and practical. Though written only for 
the physician it cannot fail to attract attention from the intelli- 
gent layman everywhere. Especially will it be welcome to the 
sufferers from Consumption, c^nceh, Pyaemia, Necrosis and 
all forms of blood-poisoning, and Malaria. 

"For the matter of this volume Dr. Cooke confesses his large indebtedness 
toDr Declat; but the remarkable cures of tuberculosis, cancer, septicaemia, 
eczema and malarial fevers recorded in the latter half of the book are 
strictly original. The only treatise on the subject in the language, it must 
inevitably fall under the eye of every intelligent physician, and the present 
notice may therefore be limited to a description of its contents. The^e con- 
sist of an introduction, which not more lucidly sets forth the teachings of 
Declat than it effectually demolishes the claims of his rivals, Lemaire and 
Lifter* some remarks on antiseptics in general, giving preference to phenic 
acid and the protochloride of i ron prepared according to Boudreaux's 
method ■ and an examination of phenic aci( ^ Dotn in its cn emical and thera- 
peutical' aspects. Besides all this we have directions for the use of the 
hypodermic syringe; and last, and most interesting ot all to the laity who 
care little how they are cured, full accounts of a number of cases that have 
been successfully treated by the method of Declat. The average medical 
man, who is more likely to close his ears to the voice of the sage than to the 
song of the siren, will skim lightly over the cases of cancer, aud say m his 
easy, superior way, that not one of them was a case of true cancer. He will 
certainly say this to his own patients, for whose enlightenment it may be 
well to mention that Dr. Cooke is an Emeritus Professor of Diagnosis. Dr. 
Cooke has been wonderfully fortunate in his use of the new remedy, but he 
has the candor to admit that he has not always been victorious — ltie uucago 
Tribune, Sept. 11th, 1882. 

" 'Antiseptic Medication 1 is a small volume bv Dr. N. F Cooke, of the 
Hahnemann Medical College of this city, avowedly a treatise on the meory 
and method of Dr. Declat, a recent visitor from the old world, which have 
attracted a great deal of attention of late. It is prettv generally sate to 
suspect something of exaggeration in almost anything which take* so e "oaen 
a hold upon popular enthusiasm, but it must be said, from hastily panning 
through Dr. Cooke's advance sheets, that he makes out a pretty strong case. 

The Vbject-matter treated of in Dr Cooke's book belongs ' e^cially to 
the medical profession, and the volume can scarcely fail ^ ^ViU to fore^ne 
interest to all of that profession not " hide-bound, 1 ' as it is called, m foregone 

conclusions. .. 

It is clearly the work of an earnest, thoughtful, and scientific .man even if 
nothing else was known of the author."- Chicago Times, Sept. 11th, l»«. 

Sent free on receipt of price. 

GROSS & DELBRIDGE, Publishers, 

48 Madison St., CHICAGO. 



GROSS & DELBRIDGE'S Publications 



A Compendium of Venereal Diseases, For Practi- 
tioners and Students; being a condensed description of those 
affections and their Homoeopathic Treatment. By E. C. 
Franklin, M. D., Piofessor of Surgery in the Homoeopathic 
Department of the University of Michigan ; Surgeon to the 
University Homoeopathic Hospital; Author of "Science and 
Art of Surgery," "A Complete Minor Surgery," etc., etc. 
About 112 pages. Octavo. 1883. Price $1.25. 

"This compendium of venereal diseases has been prepared by 
the author for the use of practitioners and students of medicine, 
as a summary only of the recent investigations and advance 
views touching the various sequelae that follow in the train of 
these contagious disorders, and to lay before the profession the 
knowledge of the present day gained by the use of compara- 
tively small doses of medicine in their treatment. 

Believing in the "dualistic theory" that the origin of the 
exciting virus which produces the local contagious ulcer, differs 
from that which develops true syphilis, the terms chancroid and 
syphilis are used to designate these two essentially distinct con- 
ditions. 

It is not intended that this little treatise shall take the place 
of the larger works on venereal diseases, but that it shall be a 
useful guide and a ready reference to the general practitioner; 
a synopsis of the more accurate and scientific observations lately 
gained in the therapeutics of these disorders. 

As such it is committed to the profession trusting that hu- 
manity may be benefited by its teachings, and that homoeopathy 
may receive the proper credit due it in the more successful treat- 
ment of these affections by attenuated medicines, which our 
brethren of the allopathic school are slowly and grudgingly 
adopting."— Extract from Dr. Franklin's Preface. 

GROSS & DELBRIDGE, Publishers, 

48 Madison St., CHICAGO. 



GROSS & DELBMDGE'S Publications. 



i 



1^ PRESS. 

How to Feed the Baby. ByR.N. Tooker, M. D., Pro- 
fessor of Diseases of Children, in the Chicago Homoeopathic 
Medical College. 

This is a little work of about one hundred and fifty pages, in- 
tended to instruct mothers in the all important matter of how, 
when, and what to feed their babies. 

As the author says, in his introductory chapter, "It is not 
ntended to offer any instruction or even suggestions in the way 
of domestic medication. The writer is among those who believe 
that when a child is sick enough to need medicine, it is sick 
enough to need a doctor. 

The work is divided into some nine chapters and an appendix, * 
containing f ormulsee for the preparation of several kinds of food 
recommended in the body of the book. The contents are as 
follows : 

Chapter l.-Signs of Faulty Nutrition. Changes of color of skin in 
illy nourished babies.-Sleep-Cry-"Does the baby grow ?"- Weight of a 
healthy child at different periods— Height of same. 

Chapter II.— Peculiarities of the Digestive Organs in Infancy.— Stomach, 
Liver, Pancreas.-The different digestive juices and their action on aliment- 
ary substances-Digestion of starch, of milk, of meat-Intestinal digestion. 

Chapter III.— Nursing. Mothers who ought to nurse their babies- 
Mothers who ought not to suckle— Time of nursing— Diet of Nursing 
women— Wet nurses. 

Chapter IV.— Weaning. When to wean-How to wean— Diet of child 
after weaning. 

Chapter V.— Partial Feeding. Best food for partially fed baby— When 
to feed and when to nurse. 

Prapter VI —Hand-fed Babies. Cow's milk— Difficulty of getting sweet 
and fresh in cities-How to keep milk sweet-Test for pure milk-Trouble 
from giving baby all milk-One cow's milk-Condensed milk. 

Chapter mi.-Artificial Foods. -Different kinds of cereals used in- 
Ridges 1 Food, Graham's, Horlick's Food— How to prepare-Other foods. 

Chapter VIII. -Adjuncts of Feeding. Value of fresh air and exercise, 
bathing, sunlight, etc. 

Chapter IX.-How not to do it. No crude drugs f or babies-"Soothing 
sirups"— Paregoric, dietetic aphorisms. 

All orders should be addressed to 

GROSS & DELBRIDGE, Publishers, 

48 Madison St., CHICAGO. 



GROSS & DELBRIDGE'S PUBLICATIONS 

lectures on Fevers. By J. R. Kippax, M D., L L. B., 
Professor of Principles and Practice of Medicine in the Chi- 
cago Homoeopathic Medical College ; Clinical Lecturer and 
Visiting Physician to the Cook County Hospital; Author 
of "Handbook of Skin Diseases/' etc. 

The work will comprise thirty lectures, embracing every form 
of Fever; their Definition, History, Etiology, Pathology, and 
Homoeopathic treatment, making a most important and valuable 
addition to our literature. About 500 pages. Octavo. 

LECTURE I.— Fevers. Introduction. Classification of Fevers. Mias- 
matic, or Malarial. Miasmatic-Contagious, and Contagious. The Ther- 
mometry of Fevers . 

LECTURE II.— Fevers. Simple Continued Fever.— Malarial Fevers. 
Laws of Malarial, Miasmatic. Geographical Distribution, and Incubation. 

LECTURE III.— Intermittent Fevers —Intermittent Pever. Defini- 
tion. Synonym. Historical Notice. Etiology. Clinical History. Types 
of Intermittent. Morbid Anatomv. and Differential Diagnosis. 

LECTURE IV.— Intermittent Fever (continued). Complications 
and Sequelae. Prognosis. Chart of Characteiistics. Prophylaxis. Treat- 
ment. 

LECTURE V.— Remittent Fever. Definition. Syncnym. Historical 
Notice. Etiology. * -linical History. Morbid Anatomy. 

LECTURE VI.— Remit tent Fever (continued.) Differential Diagnosis 
Complications, and Sequelae. Prognosis. Chart of Characteristics. Treat- 
ment. 

LECTURE VII.— Pernicious Malarial Fever Definition. Synonym. 

Historical Notice. Etiology, and Clinical History. Types of Pernicious 
Malarial Fever. Duration. Morbid Anatomy. Differential Diagnosis. 
Complications, and Sequelae. Prognosis. Chart of Characteristics. Treat- 
ment. Chronic Malarial Infection. 

LECTURE VIII— Dengue. Definition. Synonym. Historical Survey. 
Etiology. Clinical History Duration. Morbid Anatomy. Differential 
Diagnosis. Prognosis. Chart o*f Characteristics. Treatment. 

LECTURE IX.— Hay Fever. Definition. Synonym. History and 
Statistics. Etiology. Clinical History. Differential Diagnosis. Prognosis. 
Prophylaxis. Treatment. 

LECTURE X. — Typho- Malarial Fever. — Definition. Synonym. 
Historical Notice. Etiology. Types of Typho -Malarial Fever. Clinical 
Historv. Duration. 

LECTURE XI. — Typho-Malarial Fever (continued). Morbid Anat- 
omy. Complications and Sequelae. Differential Diagnosis. Prognosis. 
Chart of Characteristics. Treatment. 

LECTURE XII. —Miasmatic-Contagious Fevers. Typhoid Fever. 
Definition Synonym. History and Statistics. Etiology. 

LECTURE XIII.— Typhoid Fever (continued.) Clinical History. 
Duration. Morbid Anatomy. 

LECTURE XIV. —Typhoid Fever (continued.) Complications and 
Sequelae. Differential Diagnosis. Prognosis. Chart of Characteristics. 
Treatment. 

LECTURE XV.— Yellow Fever. Definition. Synonym History 
and Statistics. Etiology. Clinical History. Differential 1 Diagnosis. 
Morbid Anatomy. Complications, and Sequelae Prognosis. Chart of 
Characteristics. Treatment. 

The above selections from table of contents will give the 
reader some idea of the value of this new book. The work is 
now in press and will be ready about January 1st, 1883. 

GRO^S & DELBRIDGE, Publishers, 

48 Madison St., CHICAGO. 



GROSS & DELBRIDGE'S Publications. 



I N PRESS,— Ready March, 1883 , 

The American Homoeopathic Dispensatory. Designed 
as a Text- Book for the Physician, Pharmacist and Student. 
About 500 pp. octavo. Illustrated. 

This important work is written in a plain and concise manner 
by a gentleman of large experience as a pharmacist, and who 
seems therefore to have fully comprehended the long felt want 
of a reliable and scientific pharmacopoeia. 

Indeed we can safely assert that this work will be to the 
Homoeopathic School what the United States Dispensatory now 
is to the Allopathic School, a desideratum. 

The American Homoeopathic Dispensatory. 

was conceived, born and bred as a pharmaceutical text-book, 
and, as such, is intended for the druggist, the student, and the 
physician. In brief, the contents are but a series of modern 
practical paragraphs, each one of which is equally important. 
Not in any one instance is there any attempt made to contort or 
re arrange the subject matter of other Homoeopathic Pharma- 
copoeias, but, the work is wholly original and replete with prac- 
tical information. 

It is the Book for Practical Instruction, 

The volume will be an octavo of about 500 pages; printed on 
the best paper, and bound in the best manner. Ee sure and buy 
no work on the subject until you have seen and examined 
" The American Homoeopathic Dispensatory ." 

All orders should be addressed to 

GROSS & DELBRIDGE, Publishers, 

48 Madison St., CHICAGO. 



GROSS & DELBBIDGES PUBLICATIONS. 

The Physician's Condensed Account Book. An 

Epitomized System of Book-Keeping, avoiding the necessity 
of separate Journal, Day Book and Ledger, combining sys- 
tem, accuracy and easy reference, with a minimum of 
labor. 272 pages. Price, $3.50. 

The book furnishes an entirely unique system of keeping 
books for physicians. No separate Day Book, Journal or 
Ledger is required. The doctors whole month's business is 
spread out before him on a double page, and each patron for 
the month has a line all to himself. In posting the book for the 
month, there is a column of charges against each patient treated; 
another column in which that patient's unpaid balance of old 
account is brought forward; another column totals due, cash 
paid, etc. Opposite each name is a column for the patients resi- 
dence, street and number, the year and the month. The system 
is simple and plain. 

"The book is the best 1 ever saw. All before your eyes. 
Have made some collections already which were forgotten, be- 
cause not seen- Every physician should have one." 

Charles E. Pinkham, M. D , Woodland, Cal. 

Gentlemen: I have received the Physicians Condensed Ac- 
count Book, and am very much pleased with it. I pronounce 
itja grand success. ;j. Deitrick, M. D., Petrolia, Pa. 

Gross & Delbridge, 

Gentlemen: The Account Book came to hand all right. After 
a trial we can truly say that we are very much pleased with it. 
It is all any medical man can ask in the way of book-keeping. 
By using every other line we are enabled to keep a record of 
our prescriptions, and we thus have a complete picture of our 
business before us. We have no hesitation in recommending 
it to the busy practitioner. Yours, • 

Drs. Dayfoot & McKay, Mt. Morris, N. 1*. 

Gross & Delbridge, 

Gentlemen: Having used the Physician's Condensed Account 
Book for a year past, I am prepared to speak intelligently as to 
its merits, and I truly regard it as the Ne plus ultra of book- 
keeping for the busy practitioner. My accounts are always in 
order. It combines accuracy with condensation, 

R. N. Tooker, M. D., Chicago. 

GROSS & DELBRIDGE, Publishers, 

48 Madison St., CHICAGO. 



IniDortant to Physicians. 



DEY TESTS FOE ALBUMIN 

AND 

Sugar in the Urine. 



The disadvantages attendant upon the use of strong acids * 
and alkalies in clinical examinations of the urine are so well 
known as not to need enumeration ; the stains made by 
nitric acid on the clothing, its caustic action on the skin, 
to say nothing of the disagreeable odor evolved on boiling 
it with urine, are too well known to all physicians using it. 
The'same may be said, although to a less degree, of caustic 
potash used in Prommers test. Dr. Clifford Mitchell has 
simplified urinary analysis as far as albumin and sugar are 
concerned by bringing to the notice of practitioners, Raabe's 
dry test for albumin and Pavy's dry test for sugar. In test- 
ing for these substances no liquid is used, save the urine 
itself ; the chemicals are in the form of crystals and pellets 
one or two of which are merely dropped in to a test tube 
half or three-quarters full of urine, and the test is made. 
The simplicity, neatness, and rapidity with which the test 
for albumin and sugar can thus be made will cause these 
preparations to supersede all others. 

Sold in a neat, covered box containing two test tubes 
and brush, litmus paper etc., etc., by 

GROSS & DELBRIDGE. 

48 Madison St., Chicago. 

Price $1.00. Full directions accompany each box. 



GROSS & DELBRIDGES Publications. 



Homoeopathic Label Book, for tlie use of Phy- 
sicians and Pharmacists, containing more than 
thirty-five hundred gummed labels in large, clear type, and 
bound in a neat and substantial manner. Price 50 cents. 

Sample Labels. 



Belladonna. Belladonna. Belladonna, 



Belladonna. Belladonna, Belladonna, 



Belladonna. Belladonna. Belladonna. 



Belladonna Belladonna. Bell adonna. 

Belladonna, Belladonna. Belladonna. 



Belladonna. Belladonna Belladonna, 



Belladonna. Belladonna. Belladonna.' 



Benzoic acid. Benzoic acid. Benzoic acid. 



Benzoic acid. Benzoic acid. Benzoic acid. 
Berberin. 



Berberin. 



Berberin. 



Berberis vulg. Berberis vnlg. Berberis vuL 



Bismuth met. Bismuth met. Bismuth met. 



Bismuth nit. Bismuth nit, Bismuth nit. 



Bismuth nit. Bismuth nit. Bismuth nit, 



Boletus sat. Boletus sat. Boletus sat. 



For Sale at all the Pharmacies, or sent free on receipt of 
price. 

GROSS & DELBRIDGE, Publishers, 

48 Madison St., CHICAGO. 



A NEW REMEDY. 



Hydrastia Eestorative Tonic. 

We desire to call the attention of invalids, who need a 
tonic without alcoholic stimulants, to the valuable remedy 
which we have prepared at the suggestion of many Homoe- 
opathic physicians. The basis of the Tonic is the highly 
valued remedy Hydrastia Canadensis or Golden Seal. The 
preparation is for the purpose of enriching the blood and 
imparting a healthy tone to the nervous system. It does 
this by arousing a normal appetite, stimulating digestion 
and assimilation, and thus aids in supplying the tissues with 
their proper food. It is useful in all conditions of physical 
debility from exhausting diseases, loss of fluids or mental 
depression, and will agree with the most delicate stomach. 

We refer to the following testimonials : 

xr n t, ,,. . 7 Chicago, July 16, 1881. 

Messrs. Gross & Delbndge : 

The ki -Restorative Tonic" 1 put up by you meets a common demand from 

my patients. I consider I am doing them a kindness by prescribing it, and 

thus preventing a resort to Quinia or the many deranging and powerful 

nostrums and preparations sold by druggists. I have never heard anv but 

good reports of the effects Yours, 

E. M. HALE, M. D. 

,, n \ n „ .'.. Chicago, July 18, 1881. 

Messrs. Gross & Delbndge : 

Gentlemen :— It gives me pleasure to recommend your "Hydrastia Tonic " 
It has served my purpose in many cases, meeting a long felt want. 

Respectfully yours, 

JULIA HOLMES SMITH, M. D. 

_, „ T , ■ ■ Chicago, July 25, 1881. 

Gentlemen:— I have prescribed the "Hydrastia Restorative Tonic" with 
the best results. I regard it as a restorative of great value in all cases of 
debility arising from impaired nutrition. MRS. M. M. GROSS, M. D. 

Palmer House. 

Gentlemen : —We have had the opportunity of thorougly testing the virtues 
of your ''Hydrastia Restorative Tonic," and have much pleasure in according 
it our hearty indorsement as a "Nutrient." In almost all cases of Female 
Debility. Dyspepsia, Hysteria and Leucorrhoea it gives fine results. We re- 
gard it as an efficient and elegant preparation. It is but a few days since 
that a lady patient recently removed to Texas, wrote to us for a pint bottle 
of the Tonic, having derived great benefit from its use whilst in the City 

Yoars Respectfully, ' * 

XT .„ T , MRS. E. UNDERWOOD. M. D. 

New Albany, Ind., W UNDERWOOD, M. D. 

Put up in Pint Bottles. Price $1, 00. A discount to Physicians. 

PREPARED ONLY BY 

GKOSS & DELBRIDGE, 

48 Madison Street, Chicago. 



